Basic Information
| Provider Information | |||||||||
| NPI: | 1558542522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEDKE | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 BELLEFONTAINE AVE | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192272727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1005 BELLEFONTAINE AVE | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192272727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50-002690 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0071002 | 05 | OH | MEDICAID |