Healthcare Provider Details

I. General information

NPI: 1528459880
Provider Name (Legal Business Name): STEPHANIE WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 S LEROY ST
FENTON MI
48430-2911
US

IV. Provider business mailing address

824 S LEROY ST
FENTON MI
48430-2911
US

V. Phone/Fax

Practice location:
  • Phone: 813-928-1151
  • Fax:
Mailing address:
  • Phone: 813-928-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703113601
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: