Provider Demographics
NPI:1053764365
Name:STEPHENS, MICHELLE M (APN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:IRVING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:401 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IL
Mailing Address - Zip Code:61561-7585
Mailing Address - Country:US
Mailing Address - Phone:309-923-2661
Mailing Address - Fax:309-923-7628
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IL
Practice Address - Zip Code:61561-7585
Practice Address - Country:US
Practice Address - Phone:309-923-2661
Practice Address - Fax:309-923-7628
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-014570363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner