Provider Demographics
NPI:1306906516
Name:EADS, STEPHANIE PERRETT (APRN, BC)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:PERRETT
Last Name:EADS
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:PERRETT
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:546 NELIA RD
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-8066
Mailing Address - Country:US
Mailing Address - Phone:662-609-2233
Mailing Address - Fax:662-226-9567
Practice Address - Street 1:119 BOONE RIDGE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4998
Practice Address - Country:US
Practice Address - Phone:423-282-1480
Practice Address - Fax:423-928-5313
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR854570363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09356261Medicaid
MS09356261Medicaid