Provider Demographics
NPI:1871873521
Name:STEPHAN, ELLEN DIANE (CNP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:DIANE
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:DIANE
Other - Last Name:LEVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4212 GRAND AVENUE
Mailing Address - Street 2:EH WEST DULUTH CLINIC
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2737
Mailing Address - Country:US
Mailing Address - Phone:218-786-3500
Mailing Address - Fax:
Practice Address - Street 1:1025 10TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEER RIVER
Practice Address - State:MN
Practice Address - Zip Code:56636-8703
Practice Address - Country:US
Practice Address - Phone:218-246-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR185045-3363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily