Basic Information
Provider Information | |||||||||
NPI: | 1346229531 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STILLEY | ||||||||
FirstName: | EMERLEE | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 621 S ILLINOIS AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | MASON CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 504015489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6414283041 | ||||||||
FaxNumber: | 6414283059 | ||||||||
Practice Location | |||||||||
Address1: | 803 9TH AVE N | ||||||||
Address2: |   | ||||||||
City: | NORTHWOOD | ||||||||
State: | IA | ||||||||
PostalCode: | 504591002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6413241221 | ||||||||
FaxNumber: | 6413241233 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2006 | ||||||||
LastUpdateDate: | 02/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R 130389-0 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | A113916 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 519150500 | 05 | MN |   | MEDICAID |