Healthcare Provider Details

I. General information

NPI: 1912330895
Provider Name (Legal Business Name): STACIA LANGAN SACKMASTER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ROXBURY RD
ROCKFORD IL
61107-5075
US

IV. Provider business mailing address

401 ROXBURY RD
ROCKFORD IL
61107-5075
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-7340
  • Fax: 815-397-7388
Mailing address:
  • Phone: 815-397-7340
  • Fax: 815-397-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209010644
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61603948
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: