Healthcare Provider Details

I. General information

NPI: 1053136317
Provider Name (Legal Business Name): STACEY WALLACE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 39TH AVE STE 120
KENOSHA WI
53144-2043
US

IV. Provider business mailing address

3825 39TH AVE STE 120
KENOSHA WI
53144-2043
US

V. Phone/Fax

Practice location:
  • Phone: 262-946-5752
  • Fax: 262-946-5765
Mailing address:
  • Phone: 262-946-5752
  • Fax: 262-946-5765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number251425-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: