| Doctor Name: | STACY L BODEN |
| NPI Number: | 1124250063 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | NP |
| License Number: | 144166 |
| Business Practice Address: | 3200 Pleasant Valley Rd West Bend, WI - 530959274 |
| Business Phone Number: | 2623343451 |
| Business Fax Number: | 2623062964 |
| Mailing Address: | 1700 W Paradise Dr, WEST BEND |
| State: | WI |
| Postal Code: | 530959795 |
| Phone Number: | 2623343451 |
| Fax Number: | 2623062964 |
| NPI Enumeration Date: | 08/11/2009 |
| NPI Last Update Date: | 08/11/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP0200X |
| License Number: | 144166 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Pediatrics |
| Taxonomy Definition: | |