Basic Information
| Provider Information | |||||||||
| NPI: | 1114366127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUTZ | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENGLAND | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1882 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301621882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093278 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 304 SHORTER AVE NW STE 201 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301654256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2013 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5545 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO2014 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 81952 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 13587606 | 01 | CAQH | OTHER | 1114366127 | 05 | NV | MEDICAID |