Provider Demographics
NPI:1346734217
Name:STEPHENSON, ELLA MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:MICHELLE
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ELLA
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1315 MILSTEAD RD NE STE 101
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3824
Mailing Address - Country:US
Mailing Address - Phone:470-217-8445
Mailing Address - Fax:470-545-0860
Practice Address - Street 1:1315 MILSTEAD RD NE STE 101
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3824
Practice Address - Country:US
Practice Address - Phone:470-545-0860
Practice Address - Fax:470-300-7778
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN200419163WA0400X, 163WC0400X, 163WI0500X, 163WP0808X, 163WA2000X, 163WC0400X, 163WP0200X, 163WP0808X, 163WW0000X, 163WA0400X
GARN400219163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003228021AMedicaid
GA003217560AMedicaid
GA003218438AMedicaid