Healthcare Provider Details

I. General information

NPI: 1790186559
Provider Name (Legal Business Name): STACY L BRAMSTEDT ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS STACY L LIEDTKE

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 35TH AVE
MOLINE IL
61265-6138
US

IV. Provider business mailing address

545 VALLEY VIEW DR
MOLINE IL
61265-6138
US

V. Phone/Fax

Practice location:
  • Phone: 309-277-3500
  • Fax: 309-277-3050
Mailing address:
  • Phone: 309-762-5560
  • Fax: 309-762-7351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.011830
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209011830
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA107683
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: