Provider Demographics
NPI:1780256784
Name:WITT, STACIE LYN (RN, BSN)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:LYN
Last Name:WITT
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LYN
Other - Last Name:BENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:W8346 W 28TH RD
Mailing Address - Street 2:
Mailing Address - City:CRIVITZ
Mailing Address - State:WI
Mailing Address - Zip Code:54114-7372
Mailing Address - Country:US
Mailing Address - Phone:920-373-0929
Mailing Address - Fax:
Practice Address - Street 1:W8346 W 28TH RD
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-7372
Practice Address - Country:US
Practice Address - Phone:920-373-0929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI113611163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI113611Medicaid