Provider Demographics
NPI:1174110035
Name:STINSON, DEIDRA J
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:J
Last Name:STINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17622 ROSEWOOD DR APT 3A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-1736
Mailing Address - Country:US
Mailing Address - Phone:798-638-0414
Mailing Address - Fax:
Practice Address - Street 1:470 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2306
Practice Address - Country:US
Practice Address - Phone:708-832-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041155868163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse