Provider Demographics
NPI:1902076284
Name:STOPPERICH, DEANNA L (NP)
Entity Type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:L
Last Name:STOPPERICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:IN
Practice Address - Zip Code:46147-9372
Practice Address - Country:US
Practice Address - Phone:765-676-5754
Practice Address - Fax:765-676-9853
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28149608A163W00000X
IN71002615A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200908760Medicaid