Provider Demographics
NPI:1285287516
Name:DONOVAN, STEPHANIE R (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:HOUCHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1445 WANDO LANDING ST
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8533
Mailing Address - Country:US
Mailing Address - Phone:843-367-8761
Mailing Address - Fax:
Practice Address - Street 1:615 JOHNNIE DODDS BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3082
Practice Address - Country:US
Practice Address - Phone:843-936-6451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22982363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care