Healthcare Provider Details

I. General information

NPI: 1073569018
Provider Name (Legal Business Name): STEPHANIE FUSSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE STE 330
GULFPORT MS
39501-2464
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502-1810
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-1234
  • Fax: 282-865-3038
Mailing address:
  • Phone: 228-575-1234
  • Fax: 228-575-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number16995
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number00025974
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number16995
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: