Healthcare Provider Details

I. General information

NPI: 1497784979
Provider Name (Legal Business Name): NICOLE STANKO P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 LINCOLN AVE PROFESSIONAL PLAZA SUITE 107
CHARLEROI PA
15022-2451
US

IV. Provider business mailing address

625 LINCOLN AVE PROFESSIONAL PLAZA SUITE 107
CHARLEROI PA
15022-2451
US

V. Phone/Fax

Practice location:
  • Phone: 724-483-4886
  • Fax: 724-483-0519
Mailing address:
  • Phone: 724-483-4886
  • Fax: 724-483-0519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT015429
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: