Healthcare Provider Details

I. General information

NPI: 1982802013
Provider Name (Legal Business Name): ANNIE DENISE STATHAM APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PARK WAY
AMERICUS GA
31709-3656
US

IV. Provider business mailing address

100 MEDICAL PARK WAY
AMERICUS GA
31709-3656
US

V. Phone/Fax

Practice location:
  • Phone: 229-944-4031
  • Fax:
Mailing address:
  • Phone: 229-944-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN111226
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: