Provider Demographics
NPI:1396898466
Name:NELSON, STEPHANIE BROOM (AUD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:BROOM
Last Name:NELSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E RYDER ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-2033
Mailing Address - Country:US
Mailing Address - Phone:217-324-2433
Mailing Address - Fax:217-324-3377
Practice Address - Street 1:220 E RYDER ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-2033
Practice Address - Country:US
Practice Address - Phone:217-324-2433
Practice Address - Fax:217-324-3377
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0006884001OtherBLUE CROSS BLUE SHIELD IL
IL0006884001OtherBLUE CROSS BLUE SHIELD IL
IL213137Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER