Provider Demographics
NPI:1780253989
Name:STALLINGS, JENNIFER RAE (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:STALLINGS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 W IRONWOOD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2639
Mailing Address - Country:US
Mailing Address - Phone:208-625-6944
Mailing Address - Fax:208-625-6945
Practice Address - Street 1:2120 W IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2639
Practice Address - Country:US
Practice Address - Phone:208-625-6944
Practice Address - Fax:208-625-6945
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID67570363LF0000X
ID39413363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily