Basic Information
Provider Information | |||||||||
NPI: | 1871251702 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLIVARES | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FULTON | ||||||||
OtherFirstName: | STEPHANIE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2020 LIME KILN RD | ||||||||
Address2: |   | ||||||||
City: | NORTH HAVERHILL | ||||||||
State: | NH | ||||||||
PostalCode: | 037745721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6033727321 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25 MOUNT EUSTIS RD | ||||||||
Address2: |   | ||||||||
City: | LITTLETON | ||||||||
State: | NH | ||||||||
PostalCode: | 035613712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034442464 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2021 | ||||||||
LastUpdateDate: | 02/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 079750-23 | NH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LF0000X | 079750-23 | NH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.