Healthcare Provider Details

I. General information

NPI: 1437779527
Provider Name (Legal Business Name): STACEY MULRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY FORTON MD

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7322 W RAWSON AVE
FRANKLIN WI
53132-8117
US

IV. Provider business mailing address

1740 N PALMER ST
MILWAUKEE WI
53212-3928
US

V. Phone/Fax

Practice location:
  • Phone: 414-433-9010
  • Fax: 414-433-9007
Mailing address:
  • Phone: 616-581-2595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81863-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: