Healthcare Provider Details

I. General information

NPI: 1245518521
Provider Name (Legal Business Name): STEPHANIE MARIE NELSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE MARIE HUMPULA-MCMAHON D.O.

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE SUITE 226
MARQUETTE MI
49855-2675
US

IV. Provider business mailing address

26374 NETWORK PL
CHICAGO IL
60673-1263
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3925
  • Fax: 906-225-4838
Mailing address:
  • Phone: 906-225-3630
  • Fax: 906-225-4537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101019369
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: