Provider Demographics
NPI:1689869588
Name:STULTS, VANESSA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:MARIE
Last Name:STULTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-1820
Mailing Address - Country:US
Mailing Address - Phone:618-443-2177
Mailing Address - Fax:
Practice Address - Street 1:100 SPRINGFIELD CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2495
Practice Address - Country:US
Practice Address - Phone:618-632-3565
Practice Address - Fax:618-632-7693
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.003207OtherMEDICAL LICENSE
MI5601005065OtherMEDICAL LICENSE