Provider Demographics
NPI:1679091219
Name:GALLAGHER, STACY LYNN (LPN)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:LYNN
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 BITTEL ST
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 BITTEL ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511
Practice Address - Country:US
Practice Address - Phone:608-921-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-04
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311116164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse