Provider Demographics
NPI:1922215722
Name:VENNUM, STEPHEN III
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:VENNUM
Suffix:III
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 1:127 MILLER CV
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-8004
Mailing Address - Country:US
Mailing Address - Phone:601-250-4815
Mailing Address - Fax:601-250-6859
Practice Address - Street 1:206 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3926
Practice Address - Country:US
Practice Address - Phone:601-250-4815
Practice Address - Fax:601-250-6859
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist