Healthcare Provider Details

I. General information

NPI: 1518433564
Provider Name (Legal Business Name): LAQUISHA M STAHL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAQUISHA M THOMPSON

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 LEE LANE
BELOIT WI
53511
US

IV. Provider business mailing address

1969 WEST HART RD
BELOIT WI
53511-2283
US

V. Phone/Fax

Practice location:
  • Phone: 608-364-2200
  • Fax: 608-364-5452
Mailing address:
  • Phone: 608-364-5689
  • Fax: 608-364-5452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018312
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9900-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number209018312
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: