Provider Demographics
NPI:1992835474
Name:STALKER, OPAL (RN)
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:
Last Name:STALKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12550 ROAD 33.75
Mailing Address - Street 2:
Mailing Address - City:MANCOS
Mailing Address - State:CO
Mailing Address - Zip Code:81328-8102
Mailing Address - Country:US
Mailing Address - Phone:970-565-8882
Mailing Address - Fax:
Practice Address - Street 1:106 W NORTH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3119
Practice Address - Country:US
Practice Address - Phone:970-565-3056
Practice Address - Fax:970-565-0647
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49634163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07496342Medicaid