Basic Information
| Provider Information | |||||||||
| NPI: | 1841679321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | WAKEENEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676723000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857432124 | ||||||||
| FaxNumber: | 7857436317 | ||||||||
| Practice Location | |||||||||
| Address1: | 826 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479601752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745833333 | ||||||||
| FaxNumber: | 5745834785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2015 | ||||||||
| LastUpdateDate: | 02/02/2018 | ||||||||
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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 | 363LF0000X | 71007619A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 300009638 | 05 | IN | MEDICAID |