Basic Information
| Provider Information | |||||||||
| NPI: | 1063872349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LENTZ | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | NIX | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4594 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395354594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282734096 | ||||||||
| FaxNumber: | 2285941765 | ||||||||
| Practice Location | |||||||||
| Address1: | 180B DEBUYS RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282734096 | ||||||||
| FaxNumber: | 2285941765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2016 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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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 | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 06935861 | 05 | MS | MEDICAID |