Provider Demographics
NPI:1902542681
Name:LINEBACK, STATHIA (LPN)
Entity type:Individual
Prefix:
First Name:STATHIA
Middle Name:
Last Name:LINEBACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 S US HIGHWAY 35 LOT 21
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-6695
Mailing Address - Country:US
Mailing Address - Phone:574-336-2384
Mailing Address - Fax:
Practice Address - Street 1:602 WOODBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1661
Practice Address - Country:US
Practice Address - Phone:574-753-3223
Practice Address - Fax:574-722-9097
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27072417A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse