Provider Demographics
NPI:1447585435
Name:DAMITIO, STEPHANIE M (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:DAMITIO
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 1:15190 COMMUNITY RD STE 230A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3483
Mailing Address - Country:US
Mailing Address - Phone:228-831-0204
Mailing Address - Fax:228-831-1868
Practice Address - Street 1:15190 COMMUNITY RD STE 230A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3483
Practice Address - Country:US
Practice Address - Phone:228-831-0204
Practice Address - Fax:228-831-1868
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876698367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR877698OtherLICENSE NUMBER