Provider Demographics
NPI:1215495700
Name:CLABOUGH, STACI MARIE (NP)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:MARIE
Last Name:CLABOUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1010 FITZWILLIAM WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-1021
Mailing Address - Country:US
Mailing Address - Phone:630-346-6716
Mailing Address - Fax:
Practice Address - Street 1:2960 ARTESIAN RD STE 144
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4876
Practice Address - Country:US
Practice Address - Phone:630-687-9206
Practice Address - Fax:630-675-1491
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.428259163W00000X
CA95017721363LF0000X
NY344145363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse