| NPI | 1790186559 |
|---|---|
| Former Name | STACY L LIEDTKE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IL 209.011830) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209011830) |
| 363LF0000X Nurse Practitioner, Family (Licence: IA A107683) | |
| Enumeration Date | 2014-09-11 |
| Last Update Date | 2016-11-01 |