Provider Demographics
NPI:1831341361
Name:SPAIN, STEPHANIE CLAIR (DNP)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:CLAIR
Last Name:SPAIN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:CLAIR
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:1900 EMPIRE BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-1934
Mailing Address - Country:US
Mailing Address - Phone:585-633-0680
Mailing Address - Fax:585-986-9181
Practice Address - Street 1:1900 EMPIRE BLVD STE 112
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-1934
Practice Address - Country:US
Practice Address - Phone:585-633-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186086208000000X
NYF381977-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ40044888Medicaid