Healthcare Provider Details

I. General information

NPI: 1366874273
Provider Name (Legal Business Name): STEPHANIE L TRICE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE LOCKETT FNP

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3978 NEW VISION DR
FORT WAYNE IN
46845-1712
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-672-4680
  • Fax: 260-458-5836
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28162213A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71004654A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71004654A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71004654A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: