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NPI Code Detail

MEDICARE: STEPHANIE WALLACE KLADIANOS NP

MEDICARE: STEPHANIE WALLACE KLADIANOS NP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse Practitioner51842WY

General Provider Information

NPI Number : 1508293325
Entity Type Code : Individual
Provider Name (Legal Business Name) : STEPHANIE WALLACE KLADIANOS NP
Provider Business Mailing Address
First Line : 625 E BROADWAY AVE
Second Line :
City : JACKSON
State : WY
Zip : 83001-8642
Country : US
Telephone Number : 307-739-6112
Fax Number :
Provider Business Practice Location Address
First Line : 625 E BROADWAY AVE
Second Line :
City : JACKSON
State : WY
Zip : 83001-8642
Country : US
Telephone Number : 307-739-6112
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/11/2013
Last Update Date : 12/16/2025

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