Provider Demographics
NPI:1073211256
Name:SOMERVILLE, STEPHANIE
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:SOMERVILLE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 S LAUREL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-8304
Mailing Address - Country:US
Mailing Address - Phone:606-770-5053
Mailing Address - Fax:606-770-5054
Practice Address - Street 1:1370 S LAUREL RD STE 1
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8304
Practice Address - Country:US
Practice Address - Phone:606-770-5053
Practice Address - Fax:606-770-5054
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3019064363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health