Healthcare Provider Details

I. General information

NPI: 1073943106
Provider Name (Legal Business Name): CORETTA STALLWORTH FNP -C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVENUE MLC 6015
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVENUE MLC 6015
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-0800
  • Fax: 513-803-0823
Mailing address:
  • Phone: 513-636-0800
  • Fax: 513-803-0823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCOA 15366 NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA-15366-NP
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.15366
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: