Provider Demographics
NPI:1205451762
Name:ENGEBRETSON, STEPHANIE (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:ENGEBRETSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 W FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2110
Mailing Address - Country:US
Mailing Address - Phone:715-630-5032
Mailing Address - Fax:
Practice Address - Street 1:N54W6135 MILL ST
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-2021
Practice Address - Country:US
Practice Address - Phone:262-421-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3618-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist