Healthcare Provider Details

I. General information

NPI: 1194818500
Provider Name (Legal Business Name): STEPHANIE MARIE BUCHHOLTZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4923 BIG BEND RD
WATERFORD WI
53185-3542
US

IV. Provider business mailing address

4923 BIG BEND RD
WATERFORD WI
53185-3542
US

V. Phone/Fax

Practice location:
  • Phone: 262-534-4963
  • Fax:
Mailing address:
  • Phone: 262-534-4963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number97425-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: