Individual ProviderStacey Allysun SullivanNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address2801 W Kinnickinnic River Pkwy Ste 260, Milwaukee, WI 53215-3631(414) 649-6780PECOS EnrollmentBased on the most recent information from CMS, provider Stacey Allysun Sullivan does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 2 days ago.Profile DetailsProvider ID1750861969Provider TypeIndividualFull NameSullivan, Stacey AllysunTitleMrs.CredentialAPNPGenderFemaleSole ProprietorNoEnumeration Date8/16/2018Last Updated11/24/2021Contact InformationPractice LocationPractice Address2801 W Kinnickinnic River Pkwy Ste 260, Milwaukee, WI 53215-3631Phone(414) 649-6780Fax(414) 649-6030Mailing LocationMailing Address3301 W Forest Home Ave, Milwaukee, WI 53215-2843Phone(414) 649-6780Fax(414) 649-6030Provider TaxonomiesCodeDescriptionLicenseCode363L00000XPrimaryDescriptionNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersLicense8624WisconsinCode163W00000XDescriptionRegistered NurseNursing Service ProvidersLicense197066WisconsinCode363LF0000XDescriptionNurse PractitionerPhysician Assistants & Advanced Practice Nursing ProvidersLicense8624WisconsinProvider IdentifiersIDDescriptionIssuerID100080881DescriptionMedicaidIssuerUnlistedWisconsin