Provider Demographics
NPI:1992922835
Name:STAMPER, MARY CLARICE (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CLARICE
Last Name:STAMPER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SILVER HILL RD
Mailing Address - Street 2:
Mailing Address - City:STONE MTN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-2213
Mailing Address - Country:US
Mailing Address - Phone:770-491-0736
Mailing Address - Fax:
Practice Address - Street 1:450 WINN WAY
Practice Address - Street 2:DEKALB CRISIS CENTER
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1715
Practice Address - Country:US
Practice Address - Phone:404-294-0499
Practice Address - Fax:404-294-0793
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN033252163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN033252OtherPROFESSIONAL LICENSE