Provider Demographics
NPI:1669800975
Name:VIDEAN, STEPHANIE (CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:VIDEAN
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2048
Mailing Address - Country:US
Mailing Address - Phone:517-780-9260
Mailing Address - Fax:
Practice Address - Street 1:760 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2048
Practice Address - Country:US
Practice Address - Phone:517-780-9260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261894363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics