Healthcare Provider Details

I. General information

NPI: 1255387676
Provider Name (Legal Business Name): STACIE N. PERSING CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACIE N MERINGOLO CRNA

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 GORDON AVE
THOMASVILLE GA
31792-6614
US

IV. Provider business mailing address

PO BOX 235019
MONTGOMERY AL
36123-5019
US

V. Phone/Fax

Practice location:
  • Phone: 229-228-2000
  • Fax:
Mailing address:
  • Phone: 334-279-1450
  • Fax: 334-279-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN180282
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: