Provider Demographics
NPI:1033581764
Name:STOVALL, SUE (RN)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:STOVALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:D
Other - Last Name:STOVALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 630B
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5202
Mailing Address - Country:US
Mailing Address - Phone:901-767-1136
Mailing Address - Fax:901-767-0476
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 630B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-767-1136
Practice Address - Fax:901-767-0476
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45107163W00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse