Provider Demographics
NPI:1114271418
Name:STALLEY, ROBERT DENNIS (APN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DENNIS
Last Name:STALLEY
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 WEAVER PKWY
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3269
Mailing Address - Country:US
Mailing Address - Phone:630-938-8850
Mailing Address - Fax:630-938-8849
Practice Address - Street 1:4405 WEAVER PKWY
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3269
Practice Address - Country:US
Practice Address - Phone:630-938-8850
Practice Address - Fax:630-938-8849
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009884363LF0000X
IL209009884363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily