Provider Demographics
NPI:1245005040
Name:WITTENBORN, STACI ALONNA (AGPCNP)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:ALONNA
Last Name:WITTENBORN
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:ALONNA
Other - Last Name:BOWLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:211 SAINT FRANCIS DR STE 15
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-3333
Practice Address - Fax:573-331-3334
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023045683363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health