Provider Demographics
NPI:1558880872
Name:RAINES, STORMI T (PA-C)
Entity type:Individual
Prefix:
First Name:STORMI
Middle Name:T
Last Name:RAINES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:IL
Practice Address - Zip Code:62476-1202
Practice Address - Country:US
Practice Address - Phone:618-395-7340
Practice Address - Fax:618-395-6020
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007436363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant