Provider Demographics
NPI:1639111552
Name:STEVENS, ELLEN C (CRNA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:STEVENS
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:PO BOX 3000
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-3000
Mailing Address - Country:US
Mailing Address - Phone:910-715-1233
Mailing Address - Fax:910-715-1943
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-1233
Practice Address - Fax:910-715-1943
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC119022367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050429Medicaid
NC8050429Medicaid