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General NPI Number Information
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NPI Number | 1255830048
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Entity Type | Individual
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Provider Name | STEPHANIE RENAE NOUROLLAH FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 02/07/2018
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Last Update Date | 03/12/2018
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Provider Practice Location Address
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Address Line | 10701 W RESEARCH DR
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City | WAUWATOSA
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State | WI
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Zip | 53226-3452
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Country | US
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Telephone | 866-574-7135
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Fax |
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Provider Business Mailing Address
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Address Line | 4777 S US HIGHWAY 45
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City | OSHKOSH
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State | WI
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Zip | 54902-7465
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WG0600X
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Taxonomy Name | Gerontology Registered Nurse
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License Number | 178574-30
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 8277-33
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License Number State | WI
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