Provider Demographics
NPI:1508129255
Name:NWALA, STEPHANIE MARIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:NWALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-1761
Mailing Address - Country:US
Mailing Address - Phone:507-831-1703
Mailing Address - Fax:507-831-4170
Practice Address - Street 1:820 2ND AVE N
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-1761
Practice Address - Country:US
Practice Address - Phone:507-831-1703
Practice Address - Fax:507-831-5668
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400340041Medicare PIN