Provider Demographics
NPI:1457994816
Name:LANOUE, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LANOUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 W STATE ROAD 434 STE 307
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5166
Mailing Address - Country:US
Mailing Address - Phone:321-841-6444
Mailing Address - Fax:407-650-1307
Practice Address - Street 1:521 W STATE ROAD 434 STE 307
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5166
Practice Address - Country:US
Practice Address - Phone:321-841-6444
Practice Address - Fax:407-650-1307
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004674363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104659100Medicaid