Provider Demographics
NPI:1073943106
Name:STALLWORTH, CORETTA (FNP -C)
Entity Type:Individual
Prefix:MRS
First Name:CORETTA
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:FNP -C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVENUE
Mailing Address - Street 2:MLC 6015
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-0800
Mailing Address - Fax:513-803-0823
Practice Address - Street 1:3333 BURNET AVENUE
Practice Address - Street 2:MLC 6015
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-0800
Practice Address - Fax:513-803-0823
Is Sole Proprietor?:No
Enumeration Date:2013-11-27
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 15366 NP363LP0808X
OHCOA-15366-NP363LF0000X
OHAPRN.CNP.15366363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1073943106OtherNPI
OH0098923Medicaid