1346572518 NPI number — NICOLE MARIE STALL NP-C

Table of content: NICOLE MARIE STALL NP-C (NPI 1346572518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346572518 NPI number — NICOLE MARIE STALL NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STALL
Provider First Name:
NICOLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346572518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 EASTVIEW AVE UNIT 6-8
Provider Second Line Business Mailing Address:
PO BOX 125
Provider Business Mailing Address City Name:
OKOBOJI
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51355-2633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-332-6001
Provider Business Mailing Address Fax Number:
712-332-6010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3301 HIGHWAY 71 UNIT 1&4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPIRIT LAKE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51360-7634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-332-6001
Provider Business Practice Location Address Fax Number:
712-332-6010
Provider Enumeration Date:
02/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  A110196 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A110196 . This is a "LICENSE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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