Provider Demographics
NPI:1730329640
Name:LEDL, STEPHANIE L (NP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:LEDL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:SKOGLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2055 S FREMONT AVE
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2206
Mailing Address - Country:US
Mailing Address - Phone:417-820-8099
Mailing Address - Fax:417-820-8093
Practice Address - Street 1:2055 S FREMONT AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2206
Practice Address - Country:US
Practice Address - Phone:417-820-8099
Practice Address - Fax:417-820-8093
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002018100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1730329640Medicaid
AR176560758Medicaid
431560263OtherTRICARE WEST
P00700785OtherRAILROAD MEDICARE
431560263OtherTRICARE WEST