Provider Demographics
NPI:1275938433
Name:FISHER, STEPHANIE LYN (OD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYN
Last Name:FISHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6777
Mailing Address - Country:US
Mailing Address - Phone:158-232-2020
Mailing Address - Fax:815-235-1712
Practice Address - Street 1:980 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6777
Practice Address - Country:US
Practice Address - Phone:158-232-2020
Practice Address - Fax:815-235-1712
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002374152W00000X
IN18003871152W00000X
IL046011687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist