Provider Demographics
NPI:1386441152
Name:STOLDER, MARY ELLEN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:STOLDER
Suffix:
Gender:
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 ROSE STREET
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603
Mailing Address - Country:US
Mailing Address - Phone:608-781-9880
Mailing Address - Fax:608-783-5426
Practice Address - Street 1:1526 ROSE STREET
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603
Practice Address - Country:US
Practice Address - Phone:608-781-9880
Practice Address - Fax:608-783-5426
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI803-033363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health