Provider Demographics
NPI:1740965300
Name:ICABONE, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ICABONE
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 1:468 CADIEUX RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1507
Mailing Address - Country:US
Mailing Address - Phone:586-498-4422
Mailing Address - Fax:
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1507
Practice Address - Country:US
Practice Address - Phone:586-498-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351051980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine