Healthcare Provider Details

I. General information

NPI: 1326414160
Provider Name (Legal Business Name): STEPHANIE KAY KERTES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date: 10/17/2021
Reactivation Date: 11/11/2021

III. Provider practice location address

5230 BECK DR STE 3
ELKHART IN
46516-9059
US

IV. Provider business mailing address

65460 W PENINSULA DR
CASSOPOLIS MI
49031-9526
US

V. Phone/Fax

Practice location:
  • Phone: 574-622-1522
  • Fax: 574-699-6588
Mailing address:
  • Phone: 574-622-1522
  • Fax: 574-699-1588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704338384
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number28184746A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: