Healthcare Provider Details

I. General information

NPI: 1356984462
Provider Name (Legal Business Name): STEPHANIE OBERHOUSEN BOYDSTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4644
  • Fax: 601-200-4645
Mailing address:
  • Phone: 601-200-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903639
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: