Provider Demographics
NPI:1922572361
Name:HALVORSON, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HALVORSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 WENTWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-1697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 WENTWORTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-1697
Practice Address - Country:US
Practice Address - Phone:612-280-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty