1255830048 NPI number — STEPHANIE RENAE NOUROLLAH FNP-BC

Table of content: STEPHANIE RENAE NOUROLLAH FNP-BC (NPI 1255830048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255830048 NPI number — STEPHANIE RENAE NOUROLLAH FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOUROLLAH
Provider First Name:
STEPHANIE
Provider Middle Name:
RENAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHULTZ
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
RENAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255830048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4777 S US HIGHWAY 45
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSHKOSH
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54902-7465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10701 W RESEARCH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-3452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-574-7135
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WG0600X , with the licence number:  178574-30 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 8277-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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