Provider Demographics
NPI:1285461822
Name:PENACHO, STEPHANIE GAIL (PMHNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GAIL
Last Name:PENACHO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9410 CALUMET AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-0018
Mailing Address - Country:US
Mailing Address - Phone:219-922-8051
Mailing Address - Fax:
Practice Address - Street 1:9410 CALUMET AVE STE 101
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-0018
Practice Address - Country:US
Practice Address - Phone:219-922-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015728A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health