Healthcare Provider Details

I. General information

NPI: 1447275284
Provider Name (Legal Business Name): STEFANIE A. HURST O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 COUNTY ROAD 42 W
SAVAGE MN
55378-4051
US

IV. Provider business mailing address

4200 COUNTY ROAD 42 W
SAVAGE MN
55378-4051
US

V. Phone/Fax

Practice location:
  • Phone: 952-895-5434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2777
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: