Provider Demographics
NPI:1861936791
Name:GOTTSCHALK, STEPHANIE LEIGH (LAC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEIGH
Last Name:GOTTSCHALK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 HANS WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2635
Mailing Address - Country:US
Mailing Address - Phone:907-978-3101
Mailing Address - Fax:
Practice Address - Street 1:1222 WELL ST
Practice Address - Street 2:SUITE 1
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-2835
Practice Address - Country:US
Practice Address - Phone:907-458-7423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116031171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist