MEDICARE: ELAINA STANFORD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Y00000X	Clinical Exercise Physiologist

General Provider Information

NPI Number	:	1770411803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELAINA STANFORD

Provider Business Mailing Address
First Line	:	2308 TIMBER FALLS DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39212-2347
Country	:	US
Telephone Number	:	601-596-5082
Fax Number	:

Provider Business Practice Location Address
First Line	:	2308 TIMBER FALLS DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39212-2347
Country	:	US
Telephone Number	:	601-596-5082
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2026
Last Update Date	:	05/11/2026

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Directions to “ ELAINA STANFORD ” Practice Location

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