Basic Information
| Provider Information | |||||||||
| NPI: | 1033111505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAHL | ||||||||
| FirstName: | TAMMIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 MENDENHALL ST | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294835226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1843821867 | ||||||||
| FaxNumber: | 1843402183 | ||||||||
| Practice Location | |||||||||
| Address1: | 2095 HENRY TECKLENBURG DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294145733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434021436 | ||||||||
| FaxNumber: | 8434021833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APN1020 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | AN0672 | 05 | SC | MEDICAID |