Basic Information
| Provider Information | |||||||||
| NPI: | 1891355913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHANNECK | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | APRN, AGNP, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16870 105TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | ATWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562099315 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 WILLMAR AVE SW | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562013556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2019 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 6641 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.