Basic Information
| Provider Information | |||||||||
| NPI: | 1952395774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WERNER | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 HEWITT BLVD | ||||||||
| Address2: | |||||||||
| City: | RED WING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550662848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
| FaxNumber: | 6512675964 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 HEWITT BLVD | ||||||||
| Address2: | |||||||||
| City: | RED WING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550662848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
| FaxNumber: | 6512675964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 23245 | NE | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 62513 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.