Provider Demographics
NPI:1497150056
Name:MYERS, STEPHANIE P (PMHNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:P
Last Name:MYERS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 BROADWAY DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3210
Mailing Address - Country:US
Mailing Address - Phone:601-288-8050
Mailing Address - Fax:
Practice Address - Street 1:2117 BROADWAY DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3210
Practice Address - Country:US
Practice Address - Phone:601-288-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS867360363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03623229Medicaid
MS1X9165OtherMS MEDICARE PTAN FOR PMHNP
MS1276690OtherCAQH NUMBER