Healthcare Provider Details

I. General information

NPI: 1881844934
Provider Name (Legal Business Name): STEPHANIE SUZANNE WALSH CST/CFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MILLSTREAM LN
OSWEGO IL
60543-8279
US

IV. Provider business mailing address

333 MILLSTREAM LN
OSWEGO IL
60543-8279
US

V. Phone/Fax

Practice location:
  • Phone: 815-786-5153
  • Fax:
Mailing address:
  • Phone: 815-786-5153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: