Basic Information
| Provider Information | |||||||||
| NPI: | 1013247931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRIE | ||||||||
| FirstName: | STEFANIE | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 912 S HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549355530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209073922 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2009 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 154623030 | WI | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 4135-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 35033500 | 05 | WI | MEDICAID |