Healthcare Provider Details

I. General information

NPI: 1871264713
Provider Name (Legal Business Name): SARA MARIE STAFFELDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA MARIE KRUTZIK

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 2ND ST
NEENAH WI
54956-2883
US

IV. Provider business mailing address

W6217 RAVEN RD
WAUSAUKEE WI
54177-9013
US

V. Phone/Fax

Practice location:
  • Phone: 920-729-3100
  • Fax:
Mailing address:
  • Phone: 920-342-8651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11666
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11666
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number11666
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: