=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316674542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE DIANE HURDA APNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2022
-----------------------------------------------------
Last Update Date | 08/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | W3275 WOLF RIVER DR
-----------------------------------------------------
City | KESHENA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54135-9202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-304-9830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N5713 RIVERSIDE DR
-----------------------------------------------------
City | SHAWANO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54166-1076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-304-9830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 12094
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------