Healthcare Provider Details

I. General information

NPI: 1750861969
Provider Name (Legal Business Name): STACEY ALLYSUN SULLIVAN APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY ALLYSUN LANSDOWNE

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY STE 260
MILWAUKEE WI
53215-3631
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-6780
  • Fax: 414-649-6030
Mailing address:
  • Phone: 414-649-6780
  • Fax: 414-649-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8624
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8624
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number197066
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: