Provider Demographics
NPI:1023316767
Name:STEFANIAK, TINA MARIE (LPN #306931-31)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:STEFANIAK
Suffix:
Gender:F
Credentials:LPN #306931-31
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN #306931-31
Mailing Address - Street 1:4530 CHARLES STREET
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-2760
Mailing Address - Country:US
Mailing Address - Phone:262-497-6813
Mailing Address - Fax:
Practice Address - Street 1:2935 S. 127TH STREET
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4025
Practice Address - Country:US
Practice Address - Phone:262-497-6813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306931-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse