Provider Demographics
NPI:1871563601
Name:STEPHENSON, ALYSSA K (DPM)
Entity type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:K
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8335
Practice Address - Country:US
Practice Address - Phone:920-926-8282
Practice Address - Fax:920-926-8971
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI866-25213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43234400Medicaid
WI1417141227Medicare PIN
WI1871563601Medicare PIN
WIU94881Medicare UPIN
WI6066690001Medicare NSC
WI000046034Medicare PIN
WI6066690002Medicare NSC