Provider Demographics
NPI:1164967774
Name:KOTALIK, STACY KRISTIN (CNP)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:KRISTIN
Last Name:KOTALIK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3306
Mailing Address - Country:US
Mailing Address - Phone:605-665-7841
Mailing Address - Fax:605-665-0546
Practice Address - Street 1:409 SUMMIT ST STE 2500
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-3739
Practice Address - Country:US
Practice Address - Phone:605-655-1710
Practice Address - Fax:605-655-1711
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001147363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily