Provider Demographics
NPI:1518756055
Name:STEPHANIE EWALS NUTRITIONAL THERAPY
Entity type:Organization
Organization Name:STEPHANIE EWALS NUTRITIONAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STJUSTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-295-6516
Mailing Address - Street 1:5120 241ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:MN
Mailing Address - Zip Code:55070-9388
Mailing Address - Country:US
Mailing Address - Phone:612-669-4851
Mailing Address - Fax:
Practice Address - Street 1:5120 241ST AVE NW
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:MN
Practice Address - Zip Code:55070-9388
Practice Address - Country:US
Practice Address - Phone:612-669-4851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center