Healthcare Provider Details

I. General information

NPI: 1952001505
Provider Name (Legal Business Name): STEPHANIE ANNE FARDAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 SE TALLGRASS LN STE 220
WAUKEE IA
50263-6817
US

IV. Provider business mailing address

PO BOX 424
DES MOINES IA
50302-0424
US

V. Phone/Fax

Practice location:
  • Phone: 515-875-9290
  • Fax:
Mailing address:
  • Phone: 515-875-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA173477
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: