Healthcare Provider Details

I. General information

NPI: 1962384107
Provider Name (Legal Business Name): STEPHANIE WATZKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 W HARRISON ST
CHICAGO IL
60607-3106
US

IV. Provider business mailing address

20 N ABERDEEN ST APT 305
CHICAGO IL
60607-3042
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-9613
  • Fax:
Mailing address:
  • Phone: 608-279-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number041464525
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: