Provider Demographics
NPI:1457846941
Name:STAE, SALLY A
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:STAE
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 1:713 STATE ST
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3744
Mailing Address - Country:US
Mailing Address - Phone:262-434-0969
Mailing Address - Fax:
Practice Address - Street 1:21400 LANCELOT DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-1633
Practice Address - Country:US
Practice Address - Phone:262-349-0867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI85462163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse