Provider Demographics
NPI:1912730748
Name:STOLPER, THALIA GWYNNE
Entity type:Individual
Prefix:
First Name:THALIA
Middle Name:GWYNNE
Last Name:STOLPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THALIA
Other - Middle Name:
Other - Last Name:NIETZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 BEACON STREET E
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246
Mailing Address - Country:US
Mailing Address - Phone:802-359-3666
Mailing Address - Fax:
Practice Address - Street 1:40 BEACON STREET E
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246
Practice Address - Country:US
Practice Address - Phone:802-359-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH069393-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health