Provider Demographics
NPI:1912330895
Name:SACKMASTER, STACIA LANGAN (APN)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:LANGAN
Last Name:SACKMASTER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5075
Mailing Address - Country:US
Mailing Address - Phone:815-397-7340
Mailing Address - Fax:815-397-7388
Practice Address - Street 1:401 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5075
Practice Address - Country:US
Practice Address - Phone:815-397-7340
Practice Address - Fax:815-397-7388
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010644363L00000X
WAAP61603948363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2302946Medicaid