Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 18003890A | IN |
N | 152W00000X | Optometrist | 5793 | OH |
NPI | 1003076530 |
---|---|
Provider Name | Stephanie Marie Baxter |
First Address | Mishawaka, IN 46545-3408 |
Second Address | Mishawaka, IN 46545-3408 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2008 |
Last Update Date | 17/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201293730 | (05) | IN |
204460005 | MEDICARE PTAN (01) | IN |
2856128 | (05) | OH |