Provider Demographics
NPI:1609376151
Name:FOULSTON, STEPHANIE ANN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:FOULSTON
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 1:4545 N 92ND STREET
Mailing Address - Street 2:ATTN: SYMBRIA
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53225
Mailing Address - Country:US
Mailing Address - Phone:414-464-3880
Mailing Address - Fax:
Practice Address - Street 1:4545 N 92ND ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53225-4807
Practice Address - Country:US
Practice Address - Phone:414-464-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5370224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant