Provider Demographics
NPI:1003630914
Name:LICHTIG, STACY LEIGH (NP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LEIGH
Last Name:LICHTIG
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:W197N12556 PRAIRIE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53076-9443
Mailing Address - Country:US
Mailing Address - Phone:414-526-1338
Mailing Address - Fax:
Practice Address - Street 1:N95W25901 COUNTY LINE RD STE F
Practice Address - Street 2:
Practice Address - City:COLGATE
Practice Address - State:WI
Practice Address - Zip Code:53017-9225
Practice Address - Country:US
Practice Address - Phone:262-628-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15927-33363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care