Basic Information
| Provider Information | |||||||||
| NPI: | 1235408691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DREW | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | KELLY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GALLAGHER, BREVER | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | KELLY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7235 OHMS LN | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528412345 | ||||||||
| FaxNumber: | 9528412346 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 GATEWAY CT STE 100 | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530958541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202046758 | ||||||||
| FaxNumber: | 8887200495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2011 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN585810 | PA | N | Nursing Service Providers | Registered Nurse | 163W00000X | R212599-6 | MN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | SP011850 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R212599-6 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 12021-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.