Provider Demographics
NPI:1356621783
Name:STOB, ELIZABETH M (NP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:STOB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:KLOMPIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 746723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6723
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:1000 28TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-2881
Practice Address - Country:US
Practice Address - Phone:616-655-7024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704250915363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460592Medicare PIN