Provider Demographics
NPI:1508112749
Name:STIVELY, DEBORAH CAROL (APRN)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:CAROL
Last Name:STIVELY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 EDMONDSON RD
Mailing Address - Street 2:
Mailing Address - City:SCREVEN
Mailing Address - State:GA
Mailing Address - Zip Code:31560-7304
Mailing Address - Country:US
Mailing Address - Phone:912-294-4846
Mailing Address - Fax:
Practice Address - Street 1:228 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0102
Practice Address - Country:US
Practice Address - Phone:912-530-6582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN119496363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health