Healthcare Provider Details

I. General information

NPI: 1154415842
Provider Name (Legal Business Name): STACY A LEIDEL APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 S PARK ST
MADISON WI
53715-1708
US

IV. Provider business mailing address

2901 W BELTLINE HWY SUITE 120
MADISON WI
53713-4226
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-3111
  • Fax: 608-263-6663
Mailing address:
  • Phone: 608-443-5500
  • Fax: 608-441-2385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number226405-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6809-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: