Healthcare Provider Details

I. General information

NPI: 1851806517
Provider Name (Legal Business Name): STEPHANIE AUTHEMENT PPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 WILKINS CIR
CASPER WY
82601-1336
US

IV. Provider business mailing address

1430 WILKINS CIR
CASPER WY
82601-1336
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPPC-1158
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: