Provider Demographics
NPI:1801390687
Name:STAHL, KIM MARIE
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:STAHL
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 1:21 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-1459
Mailing Address - Country:US
Mailing Address - Phone:607-547-9322
Mailing Address - Fax:
Practice Address - Street 1:21 WALNUT ST
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1459
Practice Address - Country:US
Practice Address - Phone:607-547-9322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY415291-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse