Provider Demographics
NPI:1245518521
Name:NELSON, STEPHANIE MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MARIE
Last Name:NELSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:HUMPULA-MCMAHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:26374 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1263
Mailing Address - Country:US
Mailing Address - Phone:906-225-3630
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 226
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3925
Practice Address - Fax:906-225-4838
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019369208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1245518521Medicaid
MI1245518521Medicaid