Provider Demographics
NPI:1205096393
Name:PFAUTZ, STEPHANIE (FNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PFAUTZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S TEBO ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:MO
Mailing Address - Zip Code:65360-1161
Mailing Address - Country:US
Mailing Address - Phone:660-647-2147
Mailing Address - Fax:660-647-2160
Practice Address - Street 1:307 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:MO
Practice Address - Zip Code:65360-1449
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO121320363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO787000016Medicare PIN