Healthcare Provider Details

I. General information

NPI: 1710257944
Provider Name (Legal Business Name): DEBORAH CHRISTINE STAFFORD CSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

1720 COLUMBUS RD
GEORGETOWN SC
29440-8439
US

V. Phone/Fax

Practice location:
  • Phone: 843-297-6986
  • Fax:
Mailing address:
  • Phone: 843-527-4269
  • Fax: 843-527-4269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number3622
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: