Basic Information
| Provider Information | |||||||||
| NPI: | 1851556658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSMAN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | OWEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544609534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152292177 | ||||||||
| FaxNumber: | 7152294450 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | OWEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544609534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152292177 | ||||||||
| FaxNumber: | 7152294450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 10/01/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3467 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3467 | 01 | WI | WI LICENSE | OTHER | 1851556658 | 05 | WI | MEDICAID |