Healthcare Provider Details

I. General information

NPI: 1861281883
Provider Name (Legal Business Name): SUZANNE MARIE STAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 CAMP BOWIE BLVD
FORT WORTH TX
76107-2690
US

IV. Provider business mailing address

3001 CROCKETT ST APT 1735
FORT WORTH TX
76107-3296
US

V. Phone/Fax

Practice location:
  • Phone: 817-735-2000
  • Fax:
Mailing address:
  • Phone: 971-279-9011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: