Basic Information
| Provider Information | |||||||||
| NPI: | 1093016040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANUSZKI | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | YVONNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194150 | ||||||||
| Practice Location | |||||||||
| Address1: | 10250 ALLIANCE RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164789208 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2010 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0068470 | 05 | OH | MEDICAID |