Healthcare Provider Details

I. General information

NPI: 1518106350
Provider Name (Legal Business Name): STEFANIE LAYNE SHRULL DI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 AL BEDEL RD
AUBURN KY
42206-9353
US

IV. Provider business mailing address

300 W 6TH ST
RUSSELLVILLE KY
42276-1414
US

V. Phone/Fax

Practice location:
  • Phone: 270-847-5723
  • Fax:
Mailing address:
  • Phone: 270-893-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: