Provider Demographics
NPI:1558361196
Name:STAUBER, MARY ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:STAUBER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16725 PEPPER LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6843
Mailing Address - Country:US
Mailing Address - Phone:262-785-1866
Mailing Address - Fax:
Practice Address - Street 1:2000 SPRING RD
Practice Address - Street 2:STE 200
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1804
Practice Address - Country:US
Practice Address - Phone:630-472-8810
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4397-7400Medicaid
WIP59920Medicare UPIN