Healthcare Provider Details

I. General information

NPI: 1396251138
Provider Name (Legal Business Name): MRS. CASSANDRA LYNN STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASSANDRA LYNN PEREZ-RODRIGUEZ

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5109 WORLD DAIRY DR
MADISON WI
53718-3807
US

IV. Provider business mailing address

1703 EXCALIBUR DR
JANESVILLE WI
53546-1332
US

V. Phone/Fax

Practice location:
  • Phone: 608-242-0220
  • Fax: 608-242-1166
Mailing address:
  • Phone: 608-931-6568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number226643-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number226643-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: