Basic Information
| Provider Information | |||||||||
| NPI: | 1972813830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRUEGER-MAXWELL | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18667 | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410180667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595723617 | ||||||||
| FaxNumber: | 8595722326 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | FORT THOMAS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410751793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595723617 | ||||||||
| FaxNumber: | 8595722326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2010 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1612 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100225590 | 05 | KY | MEDICAID |