Healthcare Provider Details

I. General information

NPI: 1689869588
Provider Name (Legal Business Name): VANESSA MARIE STULTS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SPRINGFIELD CT
O FALLON IL
62269-2495
US

IV. Provider business mailing address

818 E BROADWAY ST
SPARTA IL
62286-1820
US

V. Phone/Fax

Practice location:
  • Phone: 618-632-3565
  • Fax: 618-632-7693
Mailing address:
  • Phone: 618-443-2177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.003207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: