Healthcare Provider Details

I. General information

NPI: 1255927828
Provider Name (Legal Business Name): STEPHANIE LEANNE UNGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-9331
  • Fax: 574-237-9252
Mailing address:
  • Phone: 574-237-9331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71010693
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: