Provider Demographics
NPI:1689074155
Name:WALVATNE, STEPHANIE RAE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RAE
Last Name:WALVATNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:RAE
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3887 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2518
Mailing Address - Country:US
Mailing Address - Phone:763-427-8547
Mailing Address - Fax:763-576-5394
Practice Address - Street 1:3887 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2518
Practice Address - Country:US
Practice Address - Phone:763-427-8547
Practice Address - Fax:763-576-5394
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR135327-7363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner