Provider Demographics
NPI:1811630494
Name:O'HALLORAN-WILKERSON, STEPHANIE NICOLE (PPHMP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:O'HALLORAN-WILKERSON
Suffix:
Gender:F
Credentials:PPHMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:MO
Mailing Address - Zip Code:65668-0125
Mailing Address - Country:US
Mailing Address - Phone:417-745-0103
Mailing Address - Fax:
Practice Address - Street 1:406 S DALLAS ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:MO
Practice Address - Zip Code:65767
Practice Address - Country:US
Practice Address - Phone:417-993-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022008045363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2022008045OtherSTATE LICENSE