Provider Demographics
NPI:1720812183
Name:PEDDY, STEPHANIE WHITE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:WHITE
Last Name:PEDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N 11TH ST STE P2280
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1525
Mailing Address - Country:US
Mailing Address - Phone:409-236-1600
Mailing Address - Fax:
Practice Address - Street 1:755 N 11TH ST STE P2280
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1525
Practice Address - Country:US
Practice Address - Phone:409-236-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1173063363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner