Basic Information
| Provider Information | |||||||||
| NPI: | 1013111939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TICHENOR | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E GRAY ST STE 1105 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025831697 | ||||||||
| FaxNumber: | 5025832120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 1096981 | KY | N | Nursing Service Providers | Registered Nurse | General Practice | 363L00000X | 5412P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3005412 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3005412 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 093360 | 01 | KY | SIHO- NNIKY | OTHER | 7100040710 | 05 | KY | MEDICAID | P00948802 | 01 | KY | RAILROAD MEDICARE | OTHER | 200884950 | 05 | IN | MEDICAID | 50031587 | 01 | KY | PASSPORT- NNIKY | OTHER | 000000696981 | 01 | KY | ANTHEM- NNIKY | OTHER | 000040710 | 01 | KY | HUMANA- NNIKY | OTHER | 8960504 | 01 | KY | CIGNA- NNIKY | OTHER | 9152454 | 01 | KY | AETNA- NNIKY | OTHER |