Provider Demographics
NPI:1104568914
Name:STEPHAN, MARLEY ANN (FNP)
Entity type:Individual
Prefix:
First Name:MARLEY
Middle Name:ANN
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 HIGHWAY P
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-8267
Mailing Address - Country:US
Mailing Address - Phone:573-674-4470
Mailing Address - Fax:
Practice Address - Street 1:255 W HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-9076
Practice Address - Country:US
Practice Address - Phone:573-674-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022012951363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily