Provider Demographics
NPI:1326414160
Name:KERTES, STEPHANIE KAY (NP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KAY
Last Name:KERTES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65460 W PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9526
Mailing Address - Country:US
Mailing Address - Phone:574-622-1522
Mailing Address - Fax:574-699-1588
Practice Address - Street 1:5230 BECK DR STE 3
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9059
Practice Address - Country:US
Practice Address - Phone:574-622-1522
Practice Address - Fax:574-699-6588
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2024-10-18
Deactivation Date:2021-10-17
Deactivation Code:
Reactivation Date:2021-11-11
Provider Licenses
StateLicense IDTaxonomies
MI4704338384363LA2200X
IN28184746A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty