Healthcare Provider Details

I. General information

NPI: 1285403030
Provider Name (Legal Business Name): STEPHANIE STREET RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2745 HARNEY PATH STE 187
JBSA FT SAM HOUSTON TX
78234-7678
US

IV. Provider business mailing address

2814 WHEATON RD
JBSA FSH TX
78234-2673
US

V. Phone/Fax

Practice location:
  • Phone: 210-221-3201
  • Fax:
Mailing address:
  • Phone: 715-781-5742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1967566
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number262268-30
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number14937-33
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number652
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: