Provider Demographics
NPI:1124135363
Name:STEPHENS, ELIZABETH ANN (CNS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1526
Mailing Address - Country:US
Mailing Address - Phone:574-722-5151
Mailing Address - Fax:574-732-0504
Practice Address - Street 1:655 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2662
Practice Address - Country:US
Practice Address - Phone:765-472-1931
Practice Address - Fax:765-472-1945
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28112839A364SP0808X
IN70000145A163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN70000145BOtherCSR
IN70000145BOtherCSR
INP99523Medicare UPIN
IN70000145BOtherCSR
INP00113488Medicare ID - Type UnspecifiedMEDICARE RR