Provider Demographics
NPI:1942542717
Name:STUBBS, TAMALA SURELL
Entity Type:Individual
Prefix:MRS
First Name:TAMALA
Middle Name:SURELL
Last Name:STUBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 A LUMBERTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-3515
Mailing Address - Country:US
Mailing Address - Phone:601-736-9980
Mailing Address - Fax:
Practice Address - Street 1:501 LUMBERTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3515
Practice Address - Country:US
Practice Address - Phone:601-736-9980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251E00000X, 374U00000X, 376J00000X, 385H00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07728803Medicaid