=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447453402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE D. MYRACLE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 89 HOSPITAL DR STE A-UP1
-----------------------------------------------------
City | BREVARD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28712-4837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-570-5505
-----------------------------------------------------
Fax | 828-259-2581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 89 HOSPITAL DR STE A-UP1
-----------------------------------------------------
City | BREVARD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28712-4837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-570-5505
-----------------------------------------------------
Fax | 828-259-2581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 2007-01974
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number | 2007-01974
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 2007-01974
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------