Provider Demographics
NPI:1790186559
Name:BRAMSTEDT, STACY L (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:L
Last Name:BRAMSTEDT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:LIEDTKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:545 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:309-762-5560
Mailing Address - Fax:309-762-7351
Practice Address - Street 1:608 35TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6138
Practice Address - Country:US
Practice Address - Phone:309-277-3500
Practice Address - Fax:309-277-3050
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011830363LF0000X
IAA107683363LF0000X
IL209.011830363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400311290Medicare PIN