=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477166338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATALIE EBERL STACKLIN-JARVIS NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2020
-----------------------------------------------------
Last Update Date | 12/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 428 WASHINGTON ST
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-4832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-561-1412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 N JEFFERSON ST
-----------------------------------------------------
City | CARTHAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13619-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-561-1412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 310259
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0027297
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN.417228
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------