Provider Demographics
NPI:1427014331
Name:PRESTON, STEPHANIE LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:PRESTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5545
Mailing Address - Country:US
Mailing Address - Phone:765-742-4950
Mailing Address - Fax:
Practice Address - Street 1:811 S 9TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5545
Practice Address - Country:US
Practice Address - Phone:765-742-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2018-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28140106A367500000X
OH019755367500000X
IL209014268367500000X
MI4704239128367500000X
FL9485336367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200822890Medicaid
IN000000479193OtherANTHEM PROVIDER NUMBER
IN9434123OtherPHCS PID NUMBER
IN815500D9Medicare PIN
INP00354196Medicare PIN