Healthcare Provider Details

I. General information

NPI: 1164866562
Provider Name (Legal Business Name): STEPHANIE BOTTORF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13831 CHALCO VALLEY PKWY SUITE 101
OMAHA NE
68138-6101
US

IV. Provider business mailing address

13831 CHALCO VALLEY PKWY SUITE 101
OMAHA NE
68138-6101
US

V. Phone/Fax

Practice location:
  • Phone: 402-592-5244
  • Fax:
Mailing address:
  • Phone: 402-592-5244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10959
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: