Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 71007750A | IN |
NPI | 1003314246 |
---|---|
Provider Name | Stephanie Ann Clouse |
First Address | Fort Wayne, IN 46804-7934 |
Second Address | Fort Wayne, IN 46804-4159 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2018 |
Last Update Date | 23/09/2020 |