1306906516 NPI number — MRS. STEPHANIE PERRETT EADS APRN, BC

Table of content: MRS. STEPHANIE PERRETT EADS APRN, BC (NPI 1306906516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306906516 NPI number — MRS. STEPHANIE PERRETT EADS APRN, BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EADS
Provider First Name:
STEPHANIE
Provider Middle Name:
PERRETT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALEY
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
PERRETT
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1306906516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
546 NELIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRENADA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38901-8066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-609-2233
Provider Business Mailing Address Fax Number:
662-226-9567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 BOONE RIDGE DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37615-4998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-282-1480
Provider Business Practice Location Address Fax Number:
423-928-5313
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R854570 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09356261 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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