Provider Demographics
NPI:1316557416
Name:MYERS, STEPHANIE MELINDA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MELINDA
Last Name:MYERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11310 STEWART WEIR RD
Mailing Address - Street 2:
Mailing Address - City:STEWART
Mailing Address - State:MS
Mailing Address - Zip Code:39767-5625
Mailing Address - Country:US
Mailing Address - Phone:662-552-2008
Mailing Address - Fax:
Practice Address - Street 1:700 WOODLAND DR # 1530
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1530
Practice Address - Country:US
Practice Address - Phone:662-283-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily