Provider Demographics
NPI:1669570305
Name:HERDER, STEPHANIE LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LYNN
Last Name:HERDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 NICHOLASVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1428
Mailing Address - Country:US
Mailing Address - Phone:859-252-6500
Mailing Address - Fax:859-514-0145
Practice Address - Street 1:1721 NICHOLASVILLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1428
Practice Address - Country:US
Practice Address - Phone:859-252-6500
Practice Address - Fax:859-514-0145
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37146207T00000X, 208VP0014X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT64046717Medicaid
0702101Medicare ID - Type Unspecified
C64274Medicare UPIN