Provider Demographics
NPI:1902076797
Name:WILEY, STEPHANIE KENDALL (NMNP LAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KENDALL
Last Name:WILEY
Suffix:
Gender:F
Credentials:NMNP LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W MADRONE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3090
Mailing Address - Country:US
Mailing Address - Phone:541-957-3700
Mailing Address - Fax:541-440-3589
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-957-3700
Practice Address - Fax:541-440-3589
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR092006677N5-NMPP-PP367A00000X
ORAS152549171100000X
OR092006677N5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR05066Medicaid
ORR85419Medicare UPIN