1124791512 NPI number — MRS. STEPHANIE CRESHELL RUFFIN NP

Table of content: MRS. STEPHANIE CRESHELL RUFFIN NP (NPI 1124791512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124791512 NPI number — MRS. STEPHANIE CRESHELL RUFFIN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUFFIN
Provider First Name:
STEPHANIE
Provider Middle Name:
CRESHELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124791512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2399 LONG CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39301-9342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-701-5609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 STATE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39307-5033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-282-8226
Provider Business Practice Location Address Fax Number:
601-512-0443
Provider Enumeration Date:
07/30/2021

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: 363LP0808X , with the licence number:  235559 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 904782 , 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)





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