Provider Demographics
NPI:1568738813
Name:STILIANOS, NICOLE SUZETTE HALL (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUZETTE HALL
Last Name:STILIANOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:S
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-0344
Mailing Address - Country:US
Mailing Address - Phone:765-828-1003
Mailing Address - Fax:765-828-1003
Practice Address - Street 1:777 S MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-2493
Practice Address - Country:US
Practice Address - Phone:765-828-1003
Practice Address - Fax:765-828-1030
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28177359A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201063240Medicaid
IN201063240Medicaid
INM400069774Medicare PIN