Provider Demographics
NPI:1255830048
Name:NOUROLLAH, STEPHANIE RENAE (FNP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENAE
Last Name:NOUROLLAH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:RENAE
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4777 S US HIGHWAY 45
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-7465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10701 W RESEARCH DR
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3452
Practice Address - Country:US
Practice Address - Phone:866-574-7135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI178574-30163WG0600X
WI8277-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0600XNursing Service ProvidersRegistered NurseGerontology