Basic Information
| Provider Information | |||||||||
| NPI: | 1518253640 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STELLE | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78866 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788866 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1340 CHARLES ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796968700 | ||||||||
| FaxNumber: | 7796968745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036-147440 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | 70289 | WI | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
No ID Information.