Provider Demographics
NPI:1720221518
Name:STULL, CRISTA
Entity Type:Individual
Prefix:
First Name:CRISTA
Middle Name:
Last Name:STULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:371 MAPLE DR
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:OH
Practice Address - Zip Code:44827-1336
Practice Address - Country:US
Practice Address - Phone:419-564-5890
Practice Address - Fax:419-564-5890
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.128643-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse