Provider Demographics
NPI:1801454558
Name:STANFORD, KATIE MELISSA (MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:MELISSA
Last Name:STANFORD
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:217 COLUMBUS RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1393
Mailing Address - Country:US
Mailing Address - Phone:740-200-0562
Mailing Address - Fax:949-757-6694
Practice Address - Street 1:217 COLUMBUS RD STE 105
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1393
Practice Address - Country:US
Practice Address - Phone:740-200-0562
Practice Address - Fax:949-757-6694
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024676364SP0809X
OH2018090842363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2018090842OtherSTATE OF OHIO NURSING LICENSE #