Provider Demographics
NPI:1104285196
Name:FUNK, STEVIE NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:STEVIE
Middle Name:NICOLE
Last Name:FUNK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 N CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3645
Mailing Address - Country:US
Mailing Address - Phone:773-271-4444
Mailing Address - Fax:773-271-5912
Practice Address - Street 1:5140 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3645
Practice Address - Country:US
Practice Address - Phone:773-271-4444
Practice Address - Fax:773-271-5912
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005780363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical