Basic Information
| Provider Information | |||||||||
| NPI: | 1790921914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IKEME | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 616788 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328616788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477120 | ||||||||
| FaxNumber: | 4077700661 | ||||||||
| Practice Location | |||||||||
| Address1: | 7527 STATE AVE | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661122815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133356986 | ||||||||
| FaxNumber: | 8554467151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2008 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2016015924 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS015504 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 05-41757 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | KA5102009 | 01 | KS | MEDICARE | OTHER | MA8204011 | 01 | MO | MEDICARE | OTHER |