Provider Demographics
NPI:1942573944
Name:OSBORNE, STEPHANIE A (CRNA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:A
Other - Last Name:CUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2 GOOD SAMARITAN WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2476
Mailing Address - Country:US
Mailing Address - Phone:618-889-3869
Mailing Address - Fax:618-899-3558
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0002
Practice Address - Country:US
Practice Address - Phone:217-525-5643
Practice Address - Fax:217-544-3311
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009395367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041351985OtherRN LIC
IL209009395OtherSTATE LIC