Provider Demographics
NPI:1124250063
Name:BODEN, STACY L (NP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:BODEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:VOSKUIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1700 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9795
Mailing Address - Country:US
Mailing Address - Phone:262-334-3451
Mailing Address - Fax:262-306-2964
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-334-3451
Practice Address - Fax:262-306-2964
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI144166363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics