Healthcare Provider Details

I. General information

NPI: 1104114818
Provider Name (Legal Business Name): STACEY V PEPPER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 7TH ST SE
DECATUR AL
35601-3337
US

IV. Provider business mailing address

425 CLOVERLEAF DR
ATHENS AL
35611-4423
US

V. Phone/Fax

Practice location:
  • Phone: 256-341-2000
  • Fax:
Mailing address:
  • Phone: 256-232-7341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-108573
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: