Provider Demographics
NPI:1871040659
Name:HENTRUP, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HENTRUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FERDINAND
Mailing Address - State:IN
Mailing Address - Zip Code:47532-9220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FERDINAND
Practice Address - State:IN
Practice Address - Zip Code:47532-9220
Practice Address - Country:US
Practice Address - Phone:812-639-6441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000739A313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility