Provider Demographics
NPI:1104334945
Name:BOETTO, STACEY L (DNP, FNP-C)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:L
Last Name:BOETTO
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 E ONTARIO ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2750
Mailing Address - Country:US
Mailing Address - Phone:312-535-9440
Mailing Address - Fax:
Practice Address - Street 1:142 E ONTARIO ST STE 1200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2750
Practice Address - Country:US
Practice Address - Phone:312-535-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.017015363L00000X, 363LF0000X
IL277000185363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily