Provider Demographics
NPI:1508122938
Name:SUPRENANT, STEPHANIE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:SUPRENANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:RENEE
Other - Last Name:SUPRENANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:500 W BROADWAY ST FL 5
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4008
Mailing Address - Country:US
Mailing Address - Phone:406-370-1600
Mailing Address - Fax:406-329-5864
Practice Address - Street 1:500 W BROADWAY ST FL 5
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-370-1600
Practice Address - Fax:406-329-5864
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62485208200000X
MT70012208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery