Provider Demographics
NPI:1932330818
Name:WUEST, STEPHANIE NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:WUEST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SOUTH BLVD E STE 150
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6115
Mailing Address - Country:US
Mailing Address - Phone:248-853-6300
Mailing Address - Fax:
Practice Address - Street 1:809 LAPORTE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-5801
Practice Address - Country:US
Practice Address - Phone:219-263-4977
Practice Address - Fax:219-263-4979
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301102361207Q00000X
IN01073957A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN252000075Medicare PIN
MI0N95590Medicare PIN