Provider Demographics
NPI:1104532811
Name:STALCUP, JEAN EVANS
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:EVANS
Last Name:STALCUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5472 OLD SHELL RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-3046
Mailing Address - Country:US
Mailing Address - Phone:251-378-0200
Mailing Address - Fax:
Practice Address - Street 1:5472 OLD SHELL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3046
Practice Address - Country:US
Practice Address - Phone:251-378-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF01231142363LF0000X
AL1-171524363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily