Provider Demographics
NPI:1578186839
Name:STAPLETON, KATIE MICHELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:MICHELLE
Last Name:STAPLETON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 BRITTANY CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8365
Mailing Address - Country:US
Mailing Address - Phone:309-242-1112
Mailing Address - Fax:
Practice Address - Street 1:OSF ST FRANCIS MEDICAL CENTER 530 NE GLEN OAK AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-2274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.076594208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics