Provider Demographics
NPI:1174665889
Name:SOUTHARD, STEPHANIE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 MUSGROVE RD
Mailing Address - Street 2:#105
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-5200
Mailing Address - Country:US
Mailing Address - Phone:301-989-3464
Mailing Address - Fax:301-879-2325
Practice Address - Street 1:2415 MUSGROVE RD
Practice Address - Street 2:#105
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-5200
Practice Address - Country:US
Practice Address - Phone:301-989-3464
Practice Address - Fax:301-879-2325
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR123661363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily