Provider Demographics
NPI:1972082170
Name:LANDES, STEPHANIE D (FNP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:D
Last Name:LANDES
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 OLD WOOLDRIDGE PIKE
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-3518
Mailing Address - Country:US
Mailing Address - Phone:423-201-3161
Mailing Address - Fax:
Practice Address - Street 1:192 BACON CREEK RD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8639
Practice Address - Country:US
Practice Address - Phone:606-526-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24514363LF0000X
KY3014119363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily