Provider Demographics
NPI:1932348059
Name:STIBB, STACY MARIE (DO)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:STIBB
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC PHYSICAL MEDICINE AND REHABILITATION
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2560
Mailing Address - Fax:414-266-3485
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC PHYSICAL MEDICINE AND REHABILITATION
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2560
Practice Address - Fax:414-266-3485
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS127182081P0010X, 208100000X
WI665322081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012186500Medicaid
FLHW118ZOtherMEDICARE PTAN
WI1932348059Medicaid