Provider Demographics
NPI:1770877664
Name:MOHR, STACY LEIGH (MD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:LEIGH
Last Name:MOHR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STACY
Other - Middle Name:LEIGH
Other - Last Name:QUELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4700
Practice Address - Fax:920-430-4598
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62695-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400157438Medicare Oscar/Certification