Provider Demographics
NPI:1659692200
Name:HART, STEPHANIE ANN (ARNP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ANN
Last Name:HART
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:3815 N SCHREIBER WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8362
Mailing Address - Country:US
Mailing Address - Phone:208-755-2804
Mailing Address - Fax:208-765-0277
Practice Address - Street 1:1641 E POLSTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-2668
Practice Address - Country:US
Practice Address - Phone:208-755-2804
Practice Address - Fax:208-765-0277
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID64956363LF0000X, 363L00000X
WAAP60158260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1659692200Medicaid
WAG8893299Medicare PIN