Healthcare Provider Details

I. General information

NPI: 1750029880
Provider Name (Legal Business Name): STACI CHRISTINE WUESTEWALD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S EAST ST
PONCA NE
68770-7264
US

IV. Provider business mailing address

PO BOX 645
PONCA NE
68770-0645
US

V. Phone/Fax

Practice location:
  • Phone: 402-755-2552
  • Fax: 402-755-2387
Mailing address:
  • Phone: 402-755-2552
  • Fax: 402-755-2387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR051494
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: