Provider Demographics
NPI:1407026438
Name:FALKENBERG, STACEY
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:FALKENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17700 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2006
Mailing Address - Country:US
Mailing Address - Phone:414-305-0489
Mailing Address - Fax:262-781-3080
Practice Address - Street 1:17700 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2006
Practice Address - Country:US
Practice Address - Phone:414-305-0489
Practice Address - Fax:262-781-3080
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10275-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000080125OtherMEDICARE