Healthcare Provider Details

I. General information

NPI: 1104580109
Provider Name (Legal Business Name): DERRYIN NINAYE STAMPLEY CPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 SNYDER RD
FAYETTE MS
39069-5051
US

IV. Provider business mailing address

28 SNYDER RD
FAYETTE MS
39069-5051
US

V. Phone/Fax

Practice location:
  • Phone: 601-809-6004
  • Fax:
Mailing address:
  • Phone: 601-809-6004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: