Basic Information
Provider Information | |||||||||
NPI: | 1700107307 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELLE | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KRUPKE | ||||||||
OtherFirstName: | STEPHANIE | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1025 MARSH ST | ||||||||
Address2: |   | ||||||||
City: | MANKATO | ||||||||
State: | MN | ||||||||
PostalCode: | 560014752 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5076254031 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1015 MARSH ST | ||||||||
Address2: |   | ||||||||
City: | MANKATO | ||||||||
State: | MN | ||||||||
PostalCode: | 560014752 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073854700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2010 | ||||||||
LastUpdateDate: | 12/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 210 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |   | 364S00000X | R174062-8 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |   | 363L00000X | 210 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.