Provider Demographics
NPI:1386904803
Name:DOUGLASS, STEPHANIE MACHELLE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MACHELLE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5600 GOODMAN RD
Mailing Address - Street 2:STE B
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7002
Mailing Address - Country:US
Mailing Address - Phone:662-890-7010
Mailing Address - Fax:662-772-5940
Practice Address - Street 1:5600 GOODMAN RD
Practice Address - Street 2:STE B
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7002
Practice Address - Country:US
Practice Address - Phone:662-890-7010
Practice Address - Fax:662-890-7044
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR863198363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08121826Medicaid