Provider Demographics
NPI:1578927133
Name:ROUSSEAU, STEPHANIE (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:C
Other - Last Name:SHAKR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1 ELLIOT WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3502
Mailing Address - Country:US
Mailing Address - Phone:603-663-2830
Mailing Address - Fax:
Practice Address - Street 1:1 ELLIOT WAY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103
Practice Address - Country:US
Practice Address - Phone:603-663-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH19542207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine