Provider Demographics
NPI:1841679321
Name:STEVENSON, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:WAKEENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67672-3000
Mailing Address - Country:US
Mailing Address - Phone:785-743-2124
Mailing Address - Fax:785-743-6317
Practice Address - Street 1:826 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-1752
Practice Address - Country:US
Practice Address - Phone:574-583-3333
Practice Address - Fax:574-583-4785
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007619A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300009638Medicaid