Provider Demographics
NPI:1285930230
Name:SMITH, STELLA JEANINE (CRNP, RDN)
Entity type:Individual
Prefix:MRS
First Name:STELLA
Middle Name:JEANINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRNP, RDN
Other - Prefix:
Other - First Name:STELLA
Other - Middle Name:JEANINE
Other - Last Name:HULTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:370 COURTHOUSE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1889
Mailing Address - Country:US
Mailing Address - Phone:228-865-1330
Mailing Address - Fax:228-865-1331
Practice Address - Street 1:1199 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3421
Practice Address - Country:US
Practice Address - Phone:228-865-1330
Practice Address - Fax:228-865-1331
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF1210163363LF0000X
AL1-110662363LF0000X
AL2692133V00000X
MS903220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered