MEDICARE: CAROL A STULTS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	28072562A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205115649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL A STULTS NP

Provider Business Mailing Address
First Line	:	5649 COVENTRY LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7145
Country	:	US
Telephone Number	:	260-436-6565
Fax Number	:	260-459-1130

Provider Business Practice Location Address
First Line	:	5649 COVENTRY LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7145
Country	:	US
Telephone Number	:	260-436-6565
Fax Number	:	260-459-1130

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2011
Last Update Date	:	08/06/2012

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