Provider Demographics
NPI:1033324108
Name:STOLL, CLIVET GLENARD (LPN)
Entity Type:Individual
Prefix:MR
First Name:CLIVET
Middle Name:GLENARD
Last Name:STOLL
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2201
Mailing Address - Country:US
Mailing Address - Phone:914-665-2146
Mailing Address - Fax:914-664-1470
Practice Address - Street 1:11 ARCHER AVE
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2201
Practice Address - Country:US
Practice Address - Phone:914-665-2146
Practice Address - Fax:914-664-1470
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229941164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse