Provider Demographics
NPI:1871264713
Name:STAFFELDT, SARA MARIE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:STAFFELDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:MARIE
Other - Last Name:KRUTZIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W6217 RAVEN RD
Mailing Address - Street 2:
Mailing Address - City:WAUSAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:54177-9013
Mailing Address - Country:US
Mailing Address - Phone:920-342-8651
Mailing Address - Fax:
Practice Address - Street 1:130 2ND ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-729-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11666363LG0600X, 364SA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health