Provider Demographics
NPI:1043778236
Name:STAHL, JILL NICOLE
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:NICOLE
Last Name:STAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:NICOLE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 ELECTRIC ST
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1931
Mailing Address - Country:US
Mailing Address - Phone:570-294-2341
Mailing Address - Fax:
Practice Address - Street 1:677 KIDDER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6908
Practice Address - Country:US
Practice Address - Phone:570-825-2046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA611397363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner