Provider Demographics
NPI:1902802978
Name:STORK, CAROL M (RN, FNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:STORK
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 EASTRIDGE CTR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3410
Mailing Address - Country:US
Mailing Address - Phone:715-838-2900
Mailing Address - Fax:715-838-2910
Practice Address - Street 1:2240 EASTRIDGE CENTER
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701
Practice Address - Country:US
Practice Address - Phone:715-383-2900
Practice Address - Fax:715-383-2910
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2949-033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR239107Medicaid
PN109424Medicare ID - Type Unspecified
OR239107Medicaid