Provider Demographics
NPI:1992529622
Name:MEZICK, STEPHANIE RUTH
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RUTH
Last Name:MEZICK
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 1:116 BAILEY RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-8201
Mailing Address - Country:US
Mailing Address - Phone:706-416-8775
Mailing Address - Fax:
Practice Address - Street 1:116 BAILEY RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-8201
Practice Address - Country:US
Practice Address - Phone:706-416-9889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHI-023594390200000X
ALS14704390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program