Provider Demographics
NPI:1891355913
Name:JOHANNECK, STEPHANIE JO (APRN, AGNP, CNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JO
Last Name:JOHANNECK
Suffix:
Gender:F
Credentials:APRN, AGNP, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16870 105TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:MN
Mailing Address - Zip Code:56209-9315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 WILLMAR AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3556
Practice Address - Country:US
Practice Address - Phone:320-231-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6641363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner