Provider Demographics
NPI:1285403030
Name:STREET, STEPHANIE (RN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2814 WHEATON RD
Mailing Address - Street 2:
Mailing Address - City:JBSA FSH
Mailing Address - State:TX
Mailing Address - Zip Code:78234-2673
Mailing Address - Country:US
Mailing Address - Phone:715-781-5742
Mailing Address - Fax:
Practice Address - Street 1:2745 HARNEY PATH STE 187
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7678
Practice Address - Country:US
Practice Address - Phone:210-221-3201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN1967566163W00000X
WI262268-30163W00000X
WI14937-33364S00000X
MN652364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163W00000XNursing Service ProvidersRegistered Nurse