Provider Demographics
NPI:1437779527
Name:MULRY, STACEY (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MULRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:FORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1740 N PALMER ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3928
Mailing Address - Country:US
Mailing Address - Phone:616-581-2595
Mailing Address - Fax:
Practice Address - Street 1:7322 W RAWSON AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8117
Practice Address - Country:US
Practice Address - Phone:414-433-9010
Practice Address - Fax:414-433-9007
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81863-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1437779527Medicaid