Provider Demographics
NPI:1104203058
Name:BOLLENBACH, STEPHANIE ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELAINE
Last Name:BOLLENBACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4517
Mailing Address - Country:US
Mailing Address - Phone:816-599-9499
Mailing Address - Fax:
Practice Address - Street 1:4320 WORNALL RD STE 530
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5942
Practice Address - Country:US
Practice Address - Phone:816-932-2836
Practice Address - Fax:816-932-9868
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-43151208600000X
MO2020020222208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery