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General NPI Number Information
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NPI Number | 1003630914
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Entity Type | Individual
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Provider Name | STACY LEIGH LICHTIG NP
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Gender | Female
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Dates
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Enumeration Date | 11/08/2024
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Last Update Date | 11/08/2024
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Provider Practice Location Address
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Address Line | N95W25901 COUNTY LINE RD STE F
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City | COLGATE
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State | WI
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Zip | 53017-9225
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Country | US
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Telephone | 262-628-3727
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Fax |
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Provider Business Mailing Address
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Address Line | W197N12556 PRAIRIE RIDGE CT
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City | RICHFIELD
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State | WI
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Zip | 53076-9443
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Country | US
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Telephone | 414-526-1338
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 15927-33
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License Number State | WI
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