Basic Information
| Provider Information | |||||||||
| NPI: | 1043778236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAHL | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | NICOLE | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | GORDON | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 103 ELECTRIC ST | ||||||||
| Address2: | |||||||||
| City: | CLARKS SUMMIT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184111931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702942341 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 677 KIDDER ST | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187026908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708252046 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2019 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 611397 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.