Healthcare Provider Details

I. General information

NPI: 1447585435
Provider Name (Legal Business Name): STEPHANIE M DAMITIO C.R.N.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15190 COMMUNITY RD STE 230A
GULFPORT MS
39503-3483
US

IV. Provider business mailing address

15190 COMMUNITY RD STE 230A
GULFPORT MS
39503-3483
US

V. Phone/Fax

Practice location:
  • Phone: 228-831-0204
  • Fax: 228-831-1868
Mailing address:
  • Phone: 228-831-0204
  • Fax: 228-831-1868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR876698
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: