Provider Demographics
NPI:1497084610
Name:STEWART, SHANA MARIE (NP)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:MARIE
Last Name:STEWART
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 1:100 MAGELLAN WAY
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-1987
Mailing Address - Country:US
Mailing Address - Phone:859-386-3000
Mailing Address - Fax:859-759-9369
Practice Address - Street 1:100 MAGELLAN WAY
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41015-1987
Practice Address - Country:US
Practice Address - Phone:859-386-3000
Practice Address - Fax:859-795-9369
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006946363L00000X, 363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100177950Medicaid