1629301692 NPI number — REGINA ANN STEWART CRNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629301692 NPI number — REGINA ANN STEWART CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEWART
Provider First Name:
REGINA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEWART
Provider Other First Name:
GINA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1629301692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 40480
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36640-0480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-415-1475
Provider Business Mailing Address Fax Number:
251-415-1476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 CENTER ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36604-3304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-415-1475
Provider Business Practice Location Address Fax Number:
251-415-1476
Provider Enumeration Date:
09/09/2009

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:  1-065551 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002050600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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