Provider Demographics
NPI:1811551500
Name:SHOULTS, STEPHANIE NICOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:SHOULTS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:NH
Mailing Address - Zip Code:03033-2123
Mailing Address - Country:US
Mailing Address - Phone:603-801-1272
Mailing Address - Fax:
Practice Address - Street 1:2499 GABEL RD STE 3
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-7349
Practice Address - Country:US
Practice Address - Phone:406-652-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-28
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOPT-OPT-LIC-3611152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist