Healthcare Provider Details

I. General information

NPI: 1477825693
Provider Name (Legal Business Name): STEPHANIE K NURRE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STEPHANIE K KEITH

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

860 LANGLEY CT
GRAYSLAKE IL
60030-3423
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-3521
  • Fax:
Mailing address:
  • Phone: 517-896-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number4704243963REL24001
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number219035
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209.029263
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: