Provider Demographics
NPI:1164693222
Name:STAPLETON, NICOLE (CST)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STAPLETON
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:STAPLETON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CST
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:765-448-8335
Practice Address - Street 1:1 W 240 S
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-6303
Practice Address - Country:US
Practice Address - Phone:764-448-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCERT# 85995246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000556838OtherANTHEM PROVIDER NUMBER