Healthcare Provider Details

I. General information

NPI: 1417676271
Provider Name (Legal Business Name): STACY SHANTE REDMOND NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 SIERRA CT
COLUMBUS MS
39705-1807
US

IV. Provider business mailing address

3103 SIERRA CT
COLUMBUS MS
39705-1807
US

V. Phone/Fax

Practice location:
  • Phone: 662-889-7528
  • Fax:
Mailing address:
  • Phone: 662-889-7528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number903311
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: