Provider Demographics
NPI:1902370497
Name:STICKEL, JACQUELINE SUSANN BROWN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:SUSANN BROWN
Last Name:STICKEL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 FITZGERALD ST
Mailing Address - Street 2:
Mailing Address - City:GERRARDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25420-1404
Mailing Address - Country:US
Mailing Address - Phone:540-533-1965
Mailing Address - Fax:
Practice Address - Street 1:205 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1613
Practice Address - Country:US
Practice Address - Phone:304-728-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176995363L00000X
WVAPRN97879NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024176995OtherVA APRN LICENSE
F11180017OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD
VA0001131963OtherVA RN LICENSE
APRN97879NPOtherWV APRN LICENSE
WV97879OtherWV RN LICENS