Provider Demographics
NPI:1992009179
Name:TAYLOR, STEPHANIE MARIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:TAYLOR
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 1:800 ALGOMA BLVD
Mailing Address - Street 2:KOLF SPORTS CENTER
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-3551
Mailing Address - Country:US
Mailing Address - Phone:920-424-7142
Mailing Address - Fax:
Practice Address - Street 1:800 ALGOMA BLVD
Practice Address - Street 2:KOLF SPORTS CENTER
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-3551
Practice Address - Country:US
Practice Address - Phone:920-424-7142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1170-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer