Basic Information
Provider Information | |||||||||
NPI: | 1063660173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CZECH | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1803 PATRIOT DRIVE | ||||||||
Address2: |   | ||||||||
City: | WAUSAU | ||||||||
State: | WI | ||||||||
PostalCode: | 54403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152981646 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 425 PINE RIDGE BLVD | ||||||||
Address2: | SUITE 211 | ||||||||
City: | WAUSAU | ||||||||
State: | WI | ||||||||
PostalCode: | 544014123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7158472000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2008 | ||||||||
LastUpdateDate: | 09/03/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 153685-030 | WI | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.