Provider Demographics
NPI:1063654465
Name:WARNEKE, STACEY C (APNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:C
Last Name:WARNEKE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:C
Other - Last Name:ROOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 N DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-2214
Mailing Address - Country:US
Mailing Address - Phone:608-524-6487
Mailing Address - Fax:
Practice Address - Street 1:1900 N DEWEY AVE
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-2214
Practice Address - Country:US
Practice Address - Phone:608-524-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7977-33363L00000X
MO2000165288363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063654465Medicaid
MO1700895083Medicaid
KS200622030AMedicaid
MOP19000003Medicare PIN
MO1063654465Medicaid