Basic Information
| Provider Information | |||||||||
| NPI: | 1518621465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATNE | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | BROOK | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023545677 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8901 WEST DODGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681143321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023548990 | ||||||||
| FaxNumber: | 4023548645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2021 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 113565 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.