Provider Demographics
NPI:1346572518
Name:STALL, NICOLE MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:STALL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 EASTVIEW AVE UNIT 6-8
Mailing Address - Street 2:PO BOX 125
Mailing Address - City:OKOBOJI
Mailing Address - State:IA
Mailing Address - Zip Code:51355-2633
Mailing Address - Country:US
Mailing Address - Phone:712-332-6001
Mailing Address - Fax:712-332-6010
Practice Address - Street 1:3301 HIGHWAY 71 UNIT 1&4
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-7634
Practice Address - Country:US
Practice Address - Phone:712-332-6001
Practice Address - Fax:712-332-6010
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA110196363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA110196OtherLICENSE