Provider Demographics
NPI:1316208044
Name:VANDENPUT, STACY L (CPM LICENSED MIDWIFE)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:VANDENPUT
Suffix:
Gender:F
Credentials:CPM LICENSED MIDWIFE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 DECKNER AVE
Mailing Address - Street 2:APARTMENT ONE
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-2640
Mailing Address - Country:US
Mailing Address - Phone:920-562-9058
Mailing Address - Fax:
Practice Address - Street 1:1638 DECKNER AVE
Practice Address - Street 2:APARTMENT ONE
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-2640
Practice Address - Country:US
Practice Address - Phone:920-562-9058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31-049176B00000X, 261QB0400X, 176B00000X
374J00000X, 174N00000X, 133NN1002X, 171M00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174H00000XOther Service ProvidersHealth Educator
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing