Provider Demographics
NPI:1225314131
Name:BANTELL, STEPHANIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:L
Last Name:BANTELL
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 1:610 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-9110
Mailing Address - Country:US
Mailing Address - Phone:715-284-4311
Mailing Address - Fax:715-284-0475
Practice Address - Street 1:610 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615
Practice Address - Country:US
Practice Address - Phone:715-284-4311
Practice Address - Fax:715-284-0475
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57440-20390200000X, 207Q00000X
WI3928-850390200000X
IA41109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI57440-20OtherWI STATE LICENSE
IA41109OtherIOWA STATE BOARD
WI3928-850OtherTEP