MEDICARE: JULIE R. STACKHOUSE CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	71001177A	IN
2	367A00000X	Advanced Practice Midwife	09000127A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942352802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE R. STACKHOUSE CNM

Provider Business Mailing Address
First Line	:	6920 POINTE INVERNESS WAY STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7934
Country	:	US
Telephone Number	:	260-479-3516
Fax Number	:	260-479-3520

Provider Business Practice Location Address
First Line	:	2414 E STATE BLVD
Second Line	:	SUITE 101
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4760
Country	:	US
Telephone Number	:	260-422-7455
Fax Number	:	260-422-0086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	01/30/2020

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