Individual
MRS. VANESSA MARIE STULTS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
100 SPRINGFIELD CT, O FALLON, IL 62269-2495
(618) 632-3565
(618) 632-7693
Mailing address
818 E BROADWAY ST, SPARTA, IL 62286-1820
(618) 443-2177
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085.003207
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085.003207
MEDICAL LICENSE
IL
01
—
5601005065
MEDICAL LICENSE
MI
Enumeration date
09/13/2007
Last updated
12/28/2021
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