Provider Demographics
NPI:1679039762
Name:STOLNICKI, TARA ANN (RN)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:ANN
Last Name:STOLNICKI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5367
Mailing Address - Country:US
Mailing Address - Phone:269-598-1514
Mailing Address - Fax:
Practice Address - Street 1:1911 W CENTRE AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5367
Practice Address - Country:US
Practice Address - Phone:269-342-9308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276958163WH1000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH1000XNursing Service ProvidersRegistered NurseHospice