Provider Demographics
NPI:1427234475
Name:STEVENS, KYLEEANN SOPHIA (MD)
Entity type:Individual
Prefix:
First Name:KYLEEANN
Middle Name:SOPHIA
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8271 SPRING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-5517
Mailing Address - Country:US
Mailing Address - Phone:703-244-1958
Mailing Address - Fax:
Practice Address - Street 1:100 FREEMAN DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-3504
Practice Address - Country:US
Practice Address - Phone:507-985-2009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-20
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0368202084F0202X, 2084P0800X
MN586892084F0202X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry