Provider Demographics
NPI:1639335102
Name:STOCKDALE, NANCY KITTREDGE (PAC)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:KITTREDGE
Last Name:STOCKDALE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:914 PINEHURST RD SE
Mailing Address - Street 2:STE 102
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2219
Mailing Address - Country:US
Mailing Address - Phone:505-896-9412
Mailing Address - Fax:505-896-9461
Practice Address - Street 1:914 PINEHURST RD SE
Practice Address - Street 2:STE 102
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-2219
Practice Address - Country:US
Practice Address - Phone:505-896-9412
Practice Address - Fax:505-896-9461
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA 2008-0035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF10999Medicare UPIN