Provider Demographics
NPI:1750055653
Name:STULL, JESSICA (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:STULL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:600 W MAIN ST STE 330
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3384
Practice Address - Country:US
Practice Address - Phone:937-980-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0028389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily