Provider Demographics
NPI:1386187615
Name:COLESTOCK, STEPHANIE (RN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:COLESTOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 OTTER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4848 OTTER LAKE RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2902
Practice Address - Country:US
Practice Address - Phone:651-399-9144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN163W0000X- RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR 1713231OtherMN BOARD OF NURSING RN LICENSE