Healthcare Provider Details

I. General information

NPI: 1649613159
Provider Name (Legal Business Name): KIMBERLY SUE STULL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N RILEY AVE
INDIANAPOLIS IN
46201-2923
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-0233
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number28137802A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: