Healthcare Provider Details

I. General information

NPI: 1942672928
Provider Name (Legal Business Name): NICOLE LEANN STENNETT MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8141 DORADO DR
ODESSA TX
79765-8533
US

IV. Provider business mailing address

8141 DORADO DR
ODESSA TX
79765-8533
US

V. Phone/Fax

Practice location:
  • Phone: 432-563-3113
  • Fax: 432-563-4206
Mailing address:
  • Phone: 432-563-3113
  • Fax: 432-563-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10214
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: