Provider Demographics
NPI:1215207428
Name:STEPHENSON, MALIA LINDA (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MALIA
Middle Name:LINDA
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 KELLER PKWY STE 108-429
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3686
Mailing Address - Country:US
Mailing Address - Phone:972-771-2011
Mailing Address - Fax:877-292-3457
Practice Address - Street 1:2813 W SOUTHLAKE BLVD STE 130
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6848
Practice Address - Country:US
Practice Address - Phone:580-771-2011
Practice Address - Fax:877-292-3457
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104379367500000X
TX828628367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8730UDOtherBCBS PIN
TX311867102Medicaid
TXP01446761OtherRR
TX8846UGOtherBCBS
TX311867101Medicaid
TXP01138497OtherRAILROAD MEDICARE
TX8730UDOtherBCBS PIN
TX8846UGOtherBCBS