Provider Demographics
NPI:1093069619
Name:STACY, HELENE R (NP)
Entity Type:Individual
Prefix:
First Name:HELENE
Middle Name:R
Last Name:STACY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HELENE
Other - Middle Name:R
Other - Last Name:SERWATKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-955-4170
Mailing Address - Fax:414-955-6543
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-955-4170
Practice Address - Fax:414-955-6543
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014748363LP0200X
WI5177363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1093069619Medicaid