Provider Demographics
NPI:1629378054
Name:MCCRAVY, STEPHANIE L (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:MCCRAVY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2858 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3420
Mailing Address - Country:US
Mailing Address - Phone:803-699-9073
Mailing Address - Fax:803-764-2361
Practice Address - Street 1:2858 SUNSET BLVD STE B
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3420
Practice Address - Country:US
Practice Address - Phone:803-699-9073
Practice Address - Fax:803-764-3215
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR95364364SC0200X
SC3965363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCR95364OtherNP LICENSE