Basic Information
| Provider Information | |||||||||
| NPI: | 1023375292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLET | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11645 VIXENS PATH | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210421541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104042881 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 BURDICK EXPY W | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587014406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575124 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2012 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 14725 | ND | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.