Provider Demographics
NPI:1386001154
Name:BORIS, STACI J (FNP)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:J
Last Name:BORIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:J
Other - Last Name:DOUCETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-454-4229
Mailing Address - Fax:920-993-5001
Practice Address - Street 1:2500 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:866-455-8111
Practice Address - Fax:920-883-0491
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210616363LF0000X
WI10173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily