Healthcare Provider Details

I. General information

NPI: 1386904803
Provider Name (Legal Business Name): STEPHANIE MACHELLE DOUGLASS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 GOODMAN RD STE B
OLIVE BRANCH MS
38654-7002
US

IV. Provider business mailing address

5600 GOODMAN RD STE B
OLIVE BRANCH MS
38654-7002
US

V. Phone/Fax

Practice location:
  • Phone: 662-890-7010
  • Fax: 662-890-7044
Mailing address:
  • Phone: 662-890-7010
  • Fax: 662-890-2704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR863198
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: