Healthcare Provider Details

I. General information

NPI: 1043146012
Provider Name (Legal Business Name): STACCIA MCCULLEY RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 WASHINGTON ST
GRAFTON WI
53024-2103
US

IV. Provider business mailing address

1950 WASHINGTON ST
GRAFTON WI
53024-2103
US

V. Phone/Fax

Practice location:
  • Phone: 262-376-5415
  • Fax: 262-376-5414
Mailing address:
  • Phone: 262-376-5415
  • Fax: 262-376-5414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number220873-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: