Healthcare Provider Details

I. General information

NPI: 1992261671
Provider Name (Legal Business Name): STEPHANIE L KULAVIC PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N 1ST ST
SPRINGFIELD IL
62702-3778
US

IV. Provider business mailing address

PO BOX 19248
SPRINGFIELD IL
62794-9248
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: