Provider Demographics
NPI:1548374341
Name:STUART, VICKIE LEANN (CRNA)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:LEANN
Last Name:STUART
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-3606
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:450 N ROXBURY DR STE 240
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4240
Practice Address - Country:US
Practice Address - Phone:310-651-2040
Practice Address - Fax:310-651-2042
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR848474367500000X
TX767896367500000X
CANA95000963367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00004207OtherRAILROAD MEDICARE
MS640507572UQOtherAMERICAN ADMIN GROUP
MS00119524Medicaid
MS00119524Medicaid
MS302I438358Medicare PIN
MS640507572UQOtherAMERICAN ADMIN GROUP
MS430001650Medicare PIN