Provider Demographics
NPI:1801522347
Name:STALDER, SUZAN NANNETTE
Entity type:Individual
Prefix:
First Name:SUZAN
Middle Name:NANNETTE
Last Name:STALDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 WESTBORO AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1758
Mailing Address - Country:US
Mailing Address - Phone:937-631-5233
Mailing Address - Fax:
Practice Address - Street 1:2040 WESTBORO AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1758
Practice Address - Country:US
Practice Address - Phone:937-631-5233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0487891374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0487891Medicaid