Healthcare Provider Details

I. General information

NPI: 1801116942
Provider Name (Legal Business Name): KELLY C. STEGALL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 WATERS AVE STE 452
SAVANNAH GA
31404
US

IV. Provider business mailing address

4750 WATERS AVE STE 452
SAVANNAH GA
31404-6235
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-5909
  • Fax: 912-350-5914
Mailing address:
  • Phone: 912-350-5909
  • Fax: 912-350-5914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN181599
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: