Basic Information
| Provider Information | |||||||||
| NPI: | 1477102382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE VERE | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOSKAMP | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2861 NE INDEPENDENCE AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640642379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165252840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2861 NE INDEPENDENCE AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640642379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165252840 | ||||||||
| FaxNumber: | 8165252841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2019 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 2019006409 | MO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
No ID Information.