Provider Demographics
NPI:1164526703
Name:STACK, CAROL (APRN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ANNA MARSH LANE
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302
Mailing Address - Country:US
Mailing Address - Phone:802-257-7785
Mailing Address - Fax:
Practice Address - Street 1:ANNA MARSH LANE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05302
Practice Address - Country:US
Practice Address - Phone:802-257-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-00112255364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT101-0011225OtherLICENSE