Individual
STEPHANIE OLESTON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LATC
Contact information
Practice address
5510 E STATE ST, ROCKFORD, IL 61108-2381
(815) 762-4468
Mailing address
11033 S STATE ROAD 140, CLINTON, WI 53525-8442
(815) 762-4468
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
096003185
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
096003185
ILLINOIS STATE LICENSE
IL
01
—
2000007667
CERTIFICATION NUMBER
IL
Enumeration date
11/04/2016
Last updated
11/04/2016
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