Provider Demographics
NPI:1104051036
Name:STAHL, CHERYL ANN (FNP-BC)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:STAHL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-251-2100
Mailing Address - Fax:574-251-2150
Practice Address - Street 1:6301 UNIVERSITY COMMONS
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1571
Practice Address - Country:US
Practice Address - Phone:574-247-4667
Practice Address - Fax:574-271-4458
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28141968A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01089168OtherRAILROAD MEDICARE PTAN
IN201016320Medicaid
IN264180009OtherMEDICARE