Provider Demographics
NPI:1922495019
Name:PROCTOR, STACEE
Entity Type:Individual
Prefix:
First Name:STACEE
Middle Name:
Last Name:PROCTOR
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 1:6355 S 35TH ST
Mailing Address - Street 2:APT 91
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9405
Mailing Address - Country:US
Mailing Address - Phone:406-212-4461
Mailing Address - Fax:
Practice Address - Street 1:6355 S 35TH ST
Practice Address - Street 2:APT 91
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9405
Practice Address - Country:US
Practice Address - Phone:406-212-4461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI318832164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse