Provider Demographics
NPI:1639304736
Name:WALLACE, STEPHANIE MARY (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MARY
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1506 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1305
Mailing Address - Country:US
Mailing Address - Phone:920-738-2611
Mailing Address - Fax:
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1305
Practice Address - Country:US
Practice Address - Phone:920-738-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME390200000X
WI60446207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program