Provider Demographics
NPI:1922237452
Name:STANFORD, ONELLIS (FNP)
Entity Type:Individual
Prefix:
First Name:ONELLIS
Middle Name:
Last Name:STANFORD
Suffix:
Gender:F
Credentials:FNP
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-864-8454
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-575-1400
Practice Address - Fax:228-575-1414
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03335347Medicaid
MS302I505961Medicare PIN
MS302I507963Medicare PIN