Provider Demographics
NPI:1679078265
Name:WAISANEN, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WAISANEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 SPRING ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2286
Mailing Address - Country:US
Mailing Address - Phone:231-489-8298
Mailing Address - Fax:231-489-8299
Practice Address - Street 1:932 SPRING ST STE 101
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2286
Practice Address - Country:US
Practice Address - Phone:231-489-8298
Practice Address - Fax:231-489-8299
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME150513207Q00000X
MI4301503564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112471000Medicaid