Provider Demographics
NPI:1609522853
Name:WHITAKER, STEPHAN
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 W JOLENO CT
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1413
Mailing Address - Country:US
Mailing Address - Phone:414-975-3861
Mailing Address - Fax:
Practice Address - Street 1:4900 W JOLENO CT
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-1413
Practice Address - Country:US
Practice Address - Phone:414-975-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0018441311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home