Provider Demographics
NPI:1639227630
Name:STOLZ, DEBBIE GANN (LPN)
Entity Type:Individual
Prefix:
First Name:DEBBIE
Middle Name:GANN
Last Name:STOLZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 PINEHILL RD
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-7904
Mailing Address - Country:US
Mailing Address - Phone:662-728-3965
Mailing Address - Fax:662-728-3965
Practice Address - Street 1:404 PINEHILL RD
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-7904
Practice Address - Country:US
Practice Address - Phone:662-728-3965
Practice Address - Fax:662-728-3965
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP191108164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770230Medicaid