Healthcare Provider Details

I. General information

NPI: 1801454558
Provider Name (Legal Business Name): KATIE MELISSA STANFORD MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 COLUMBUS RD STE 105
ATHENS OH
45701-1393
US

IV. Provider business mailing address

217 COLUMBUS RD STE 105
ATHENS OH
45701-1393
US

V. Phone/Fax

Practice location:
  • Phone: 740-200-0562
  • Fax: 949-757-6694
Mailing address:
  • Phone: 740-200-0562
  • Fax: 949-757-6694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2018090842
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAPRN.CNP.024676
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: