Provider Demographics
NPI:1629167820
Name:STEFAN, SARA K (DC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:K
Last Name:STEFAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:ANN
Other - Last Name:KINNINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2016 COUNTY ROAD HH
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-2653
Mailing Address - Country:US
Mailing Address - Phone:773-575-8464
Mailing Address - Fax:
Practice Address - Street 1:2016 COUNTY ROAD HH
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-2653
Practice Address - Country:US
Practice Address - Phone:773-575-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010639111N00000X
WI4207-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK34049OtherMEDICARE #
IL1636757OtherBLUE CROSS ID #
ILV10951Medicare UPIN
IL1636757OtherBLUE CROSS ID #