Provider Demographics
NPI:1427198662
Name:WILLIAMS, STACEY LYNN (OTA)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 WYLDEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7694
Mailing Address - Country:US
Mailing Address - Phone:920-232-0974
Mailing Address - Fax:
Practice Address - Street 1:2300 STATE ROAD 44
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-9137
Practice Address - Country:US
Practice Address - Phone:920-233-2372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI877-027174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI877-027OtherDEPT. OF REG. AND LICENSE