Provider Demographics
NPI:1104821271
Name:STOLZ, SUSAN D (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:STOLZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4792
Mailing Address - Country:US
Mailing Address - Phone:812-339-6434
Mailing Address - Fax:812-331-0196
Practice Address - Street 1:1200 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4792
Practice Address - Country:US
Practice Address - Phone:812-339-6434
Practice Address - Fax:812-331-0196
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000073A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300012943Medicaid
INS51512Medicare UPIN
177560FMedicare ID - Type Unspecified
INM400022248Medicare PIN