Healthcare Provider Details

I. General information

NPI: 1275938433
Provider Name (Legal Business Name): STEPHANIE LYN FISHER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 W SOUTH ST
FREEPORT IL
61032-6777
US

IV. Provider business mailing address

980 W SOUTH ST
FREEPORT IL
61032-6777
US

V. Phone/Fax

Practice location:
  • Phone: 158-232-2020
  • Fax: 815-235-1712
Mailing address:
  • Phone: 158-232-2020
  • Fax: 815-235-1712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002374
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003871
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011687
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: