Healthcare Provider Details

I. General information

NPI: 1215495700
Provider Name (Legal Business Name): STACI MARIE CLABOUGH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACI JACOBS NP

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 ARTESIAN RD STE 144
NAPERVILLE IL
60564-4876
US

IV. Provider business mailing address

1010 FITZWILLIAM WAY
NORTH AURORA IL
60542-1021
US

V. Phone/Fax

Practice location:
  • Phone: 630-687-9206
  • Fax: 630-675-1491
Mailing address:
  • Phone: 630-346-6716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017721
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number344145
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.428259
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: