Provider Demographics
NPI:1053757047
Name:DAVITTO, STEPHANIE L (NP)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:DAVITTO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SAGAMORE PKWY WEST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906
Mailing Address - Country:US
Mailing Address - Phone:765-463-6722
Mailing Address - Fax:765-463-0905
Practice Address - Street 1:124 SAGAMORE PKWY WEST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906
Practice Address - Country:US
Practice Address - Phone:765-463-6722
Practice Address - Fax:765-463-0905
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004424A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201163170Medicaid
INP01588942Medicare PIN
IN264430103Medicare PIN