1568483360 NPI number — STEPHANIE ANN TIPPIN RN, MSN, FNP-C

Table of content: STEPHANIE ANN TIPPIN RN, MSN, FNP-C (NPI 1568483360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568483360 NPI number — STEPHANIE ANN TIPPIN RN, MSN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIPPIN
Provider First Name:
STEPHANIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, MSN, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAY
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, MSN, FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568483360
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1234 E. DUPONT RD.
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-373-9728
Provider Business Mailing Address Fax Number:
260-373-9740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8028 CARNAGIE BLVD.,
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-422-7455
Provider Business Practice Location Address Fax Number:
260-755-6233
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  28148314A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000638414 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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