Provider Demographics
NPI:1629460662
Name:PRESCOTT, STEVENSON
Entity Type:Individual
Prefix:MR
First Name:STEVENSON
Middle Name:
Last Name:PRESCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 SMITH CV
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-4062
Mailing Address - Country:US
Mailing Address - Phone:662-719-1593
Mailing Address - Fax:
Practice Address - Street 1:314 OLD RULEVILLE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-9592
Practice Address - Country:US
Practice Address - Phone:662-347-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant