=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497084610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANA MARIE STEWART NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2009
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MAGELLAN WAY
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41015-1987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-386-3000
-----------------------------------------------------
Fax | 859-795-9369
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MAGELLAN WAY
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41015-1987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-386-3000
-----------------------------------------------------
Fax | 859-759-9369
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 3006946
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------