Provider Demographics
NPI:1467017178
Name:DAVIS, STEPHANIE (MPA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4448 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-3346
Mailing Address - Country:US
Mailing Address - Phone:800-883-5373
Mailing Address - Fax:
Practice Address - Street 1:4448 ADAMS ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-3346
Practice Address - Country:US
Practice Address - Phone:800-883-5373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0550225067172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver