Provider Demographics
NPI:1780912915
Name:STICKLER, THOMAS L (APRN)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:STICKLER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-0030
Mailing Address - Country:US
Mailing Address - Phone:606-638-7400
Mailing Address - Fax:606-638-0468
Practice Address - Street 1:2483 HIGHWAY 644
Practice Address - Street 2:SUITE 107
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-9242
Practice Address - Country:US
Practice Address - Phone:606-638-7400
Practice Address - Fax:606-638-0468
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006204363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100097770Medicaid
KY3032480Medicaid
WV3810016489Medicaid
KY3032480Medicaid