Healthcare Provider Details

I. General information

NPI: 1558142323
Provider Name (Legal Business Name): STEPHANIE MARIE YEAKLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE MARIE YEAKLE FNP

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/09/2023
Certification Date: 08/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 STELLHORN RD
FORT WAYNE IN
46815-4631
US

IV. Provider business mailing address

2905 S 700 E
MARION IN
46953-9711
US

V. Phone/Fax

Practice location:
  • Phone: 604-839-0812
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28176331A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: