MEDICARE: STACY LYNN DUVALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	307449-31	WI

General Provider Information

NPI Number	:	1780539890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY LYNN DUVALL

Provider Business Mailing Address
First Line	:	2211 15TH AVE
Second Line	:
City	:	BLOOMER
State	:	WI
Zip	:	54724-1228
Country	:	US
Telephone Number	:	715-720-3780
Fax Number	:

Provider Business Practice Location Address
First Line	:	475 CHIPPEWA MALL DR
Second Line	:
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729-5034
Country	:	US
Telephone Number	:	715-720-3780
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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