Provider Demographics
NPI:1750861969
Name:SULLIVAN, STACEY ALLYSUN (APNP)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ALLYSUN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ALLYSUN
Other - Last Name:LANSDOWNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-649-6780
Mailing Address - Fax:414-649-6030
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 260
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3631
Practice Address - Country:US
Practice Address - Phone:414-649-6780
Practice Address - Fax:414-649-6030
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI197066163W00000X
WI8624363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100080881Medicaid