MEDICARE: MRS. ABIGAIL GRACE STUBBLEFIELD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	291278	GA
2	363LF0000X	Family Nurse Practitioner	AC005822	MD

General Provider Information

NPI Number	:	1831871896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ABIGAIL GRACE STUBBLEFIELD

Provider Business Mailing Address
First Line	:	14745 JENNIFER CT
Second Line	:
City	:	SWAN POINT
State	:	MD
Zip	:	20645-2104
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14745 JENNIFER CT
Second Line	:
City	:	SWAN POINT
State	:	MD
Zip	:	20645-2104
Country	:	US
Telephone Number	:	678-350-8083
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2023
Last Update Date	:	09/01/2023

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