Healthcare Provider Details

I. General information

NPI: 1689332835
Provider Name (Legal Business Name): STEPHANIE ANN STOEGBAUER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE OTTO

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/06/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 N GATEWAY DR
APPLETON WI
54913-7863
US

IV. Provider business mailing address

W5976 GERANIUM DR
APPLETON WI
54915-5655
US

V. Phone/Fax

Practice location:
  • Phone: 920-830-6877
  • Fax:
Mailing address:
  • Phone: 920-574-8985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11155
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: