Provider Demographics
NPI:1588141279
Name:MIKELONIS, STEPHANIE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MIKELONIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:FRIBLEYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 4440
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1171
Practice Address - Country:US
Practice Address - Phone:574-647-5300
Practice Address - Fax:574-647-5305
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002479A363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical