Provider Demographics
NPI:1205115649
Name:STULTS, CAROL A (NP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:STULTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:A
Other - Last Name:SPRINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5649 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7145
Mailing Address - Country:US
Mailing Address - Phone:260-436-6565
Mailing Address - Fax:260-459-1130
Practice Address - Street 1:5649 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7145
Practice Address - Country:US
Practice Address - Phone:260-436-6565
Practice Address - Fax:260-459-1130
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28072562A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201039990Medicaid
INM400058450Medicare PIN