Provider Demographics
NPI:1376342790
Name:STOVALL, PRESLEY DYESS
Entity type:Individual
Prefix:
First Name:PRESLEY
Middle Name:DYESS
Last Name:STOVALL
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 1:84 MADISON PL
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8328
Mailing Address - Country:US
Mailing Address - Phone:601-455-0251
Mailing Address - Fax:
Practice Address - Street 1:2200 HARDY ST STE 30
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-5928
Practice Address - Country:US
Practice Address - Phone:601-318-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS900126363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner