Provider Demographics
NPI:1265449128
Name:STALTER, NICOLE LYNN (ARNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:STALTER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:20 E LAKEVIEW DR SUITE 109
Mailing Address - City:NEDERLAND
Mailing Address - State:CO
Mailing Address - Zip Code:80466-0009
Mailing Address - Country:US
Mailing Address - Phone:970-945-2840
Mailing Address - Fax:303-258-7140
Practice Address - Street 1:1905 BLAKE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4288
Practice Address - Country:US
Practice Address - Phone:970-945-2840
Practice Address - Fax:970-945-2893
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAAO92663363L00000X
COSNP 100095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1265449128Medicaid
IA1426247Medicaid
IAI15461Medicare ID - Type Unspecified
IA719260449Medicare PIN
IA1426247Medicaid