Healthcare Provider Details

I. General information

NPI: 1922715630
Provider Name (Legal Business Name): KAITLIN CYNTHIA STOTLAR FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 HEARTLAND ST
MARION IL
62959-6393
US

IV. Provider business mailing address

3403 HEARTLAND ST
MARION IL
62959-6393
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.026293
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: