1215056718 NPI number — PHYLLIS C STACKHOUSE CRNP

Table of content: PHYLLIS C STACKHOUSE CRNP (NPI 1215056718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215056718 NPI number — PHYLLIS C STACKHOUSE CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACKHOUSE
Provider First Name:
PHYLLIS
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
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:
1215056718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
476 ROLLING RIDGE DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
STATE COLLEGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16801-7639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-689-4980
Provider Business Mailing Address Fax Number:
814-689-4990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
476 ROLLING RIDGE DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
STATE COLLEGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16801-7639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-689-4980
Provider Business Practice Location Address Fax Number:
814-689-4990
Provider Enumeration Date:
03/28/2007

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: 163W00000X , with the licence number:  RN-204012-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: SP-001330-D , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103171579 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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