Healthcare Provider Details

I. General information

NPI: 1114140290
Provider Name (Legal Business Name): D. MARIE STOUDEMIRE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 E 3RD ST
CHATTANOOGA TN
37403-2102
US

IV. Provider business mailing address

921 E 3RD ST
CHATTANOOGA TN
37403-2102
US

V. Phone/Fax

Practice location:
  • Phone: 423-209-8180
  • Fax: 209-209-8191
Mailing address:
  • Phone: 423-209-8180
  • Fax: 209-209-8191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number77193
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: