1881763811 NPI number — MRS. STACEY ANN HODGE PURVIS FNP

Table of content: MRS. STACEY ANN HODGE PURVIS FNP (NPI 1881763811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881763811 NPI number — MRS. STACEY ANN HODGE PURVIS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PURVIS
Provider First Name:
STACEY
Provider Middle Name:
ANN HODGE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAKER
Provider Other First Name:
STACEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881763811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14417
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31416-1417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-352-4777
Provider Business Mailing Address Fax Number:
912-351-0630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5354 REYNOLDS ST
Provider Second Line Business Practice Location Address:
SUITE 318
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-352-4777
Provider Business Practice Location Address Fax Number:
912-351-0630
Provider Enumeration Date:
11/06/2006

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:  RN117924 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00831872B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: RN117924 . This is a "GA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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