Provider Demographics
NPI:1992796841
Name:STANG, JILL T (ANP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:T
Last Name:STANG
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 NORTHWAY COURT
Mailing Address - Street 2:CENTRACARE CLINIC HEARTLAND
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-251-1775
Mailing Address - Fax:320-240-3131
Practice Address - Street 1:1520 NORTHWAY COURT
Practice Address - Street 2:CENTRACARE CLINIC HEARTLAND
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-251-1775
Practice Address - Fax:320-240-3131
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1237351363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
002219500OtherMEDICAL ASSISTANCE
1014181OtherPREFERRED ONE
86D79STOtherBLUE CROSS BLUE SHIELD
HP23116OtherHEALTH PARTNERS
R1237351OtherMN LICENSE NUMBER
0110555OtherMEDICA HEALTH PLANS
122925OtherU CARE
122925OtherU CARE
500000528Medicare ID - Type Unspecified
R1237351OtherMN LICENSE NUMBER