Provider Demographics
NPI:1932791928
Name:CROSS, STEPHANIE LYNN (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:CROSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60849 CLOVER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-8731
Mailing Address - Country:US
Mailing Address - Phone:574-209-0184
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD STE 208
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1465
Practice Address - Country:US
Practice Address - Phone:574-335-6000
Practice Address - Fax:574-335-0738
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28180509A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001541103OtherANTHEM
IN000001541231OtherANTHEM
IN000001541707OtherANTHEM
IN300049729Medicaid