NPIMap

Individual provider Active NPI

Stephanie Nicole Clark, CRNA

  • Certified Registered Nurse Anesthetist
  • Goldsboro, NC
National Provider Identifier
1215486444
Registry record updated Oct 2, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Certified Registered Nurse AnesthetistTaxonomy code 367500000X
License
901448 Issued in MS
Practice address
2700 Wayne Memorial Dr
Goldsboro, NC 27534-9494
Phone
(919) 731-6068
Fax
(919) 731-6025
NPI assigned
Sep 29, 2016
Last updated
Oct 2, 2018By the provider in NPPES
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Oct 2, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Certified Registered Nurse Anesthetist 367500000X 901448 MS Primary
Certified Registered Nurse Anesthetist 367500000X 111055 AL

Addresses

Primary practice location

2700 Wayne Memorial Dr
Goldsboro, NC 27534-9494

Mailing address

105 Katherine Dr
Ste G
Flowood, MS 39232-8857
Phone (919) 731-6068

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20171024002602 MS Practitioner - Certified Registered Nurse Anesthetist (Crna) 3779862933 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Certified Registered Nurse Anesthetist (Crna)
Education
Other, 2016
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Best Anesthesia PLLCGroup PAC ID 9436521168, 20 clinicians
Memorial Hospital at GulfportGroup PAC ID 2466524012, 473 clinicians
Etas PLLCGroup PAC ID 8123481934, 43 clinicians

Practice addresses (Care Compare)

150 Reynoir St
Biloxi, MS 39530-4130
Phone (228) 284-2389

4500 13TH St
Gulfport, MS 39501-2515
Phone (228) 867-3152

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Certified Registered Nurse

State licenses

LicenseStateTypeSpecialty
111055ALMDCertified Registered Nurse Anesthetist

Practice roles

OrganizationSpecialtyStatusNew patients
Northstar Anesthesia of Mississippi, LLC Single Specialty CurrentSince Aug 21, 2017 Accepting new patients
Memorial Hospital at Gulfport Single Specialty Current Accepting new patients
Etas, PLLC Single Specialty CurrentSince Jun 7, 2024 Accepting new patients
Best Anesthesia, PLLC Single Specialty CurrentSince Jan 1, 2023 Accepting new patients
Anesthesia Consultants PA Single Specialty CurrentSince Oct 1, 2018 Accepting new patients
Memorial Hospital at Gulfport Single Specialty CurrentSince Sep 14, 2021 Accepting new patients

Locations

7956 Vaughn Rd
Ste 165
Montgomery, AL 36116

150 Reynoir St
Biloxi, MS 39530
Phone (228) 284-2389

1340 Broad Ave
Ste 440
Gulfport, MS 39501
Phone (228) 867-4855

4500 13th St
Gulfport, MS 39501
Phone (228) 236-3872

4500 13th St
Fl 2
Gulfport, MS 39501
Phone (228) 865-3281

1030 River Oaks Dr
Jackson, MS 39232
Phone (601) 376-2165

2100 Highway 61 N
Vicksburg, MS 39183
Phone (601) 883-5001

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 60

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 60

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1475107200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1538438400000",
    "number": "1215486444",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "105 KATHERINE DR",
            "address_2": "STE G",
            "city": "FLOWOOD",
            "state": "MS",
            "postal_code": "392328857",
            "telephone_number": "919-731-6068",
            "fax_number": "919-731-6025"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2700 WAYNE MEMORIAL DR",
            "city": "GOLDSBORO",
            "state": "NC",
            "postal_code": "275349494",
            "telephone_number": "919-731-6068",
            "fax_number": "919-731-6025"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "STEPHANIE",
        "middle_name": "NICOLE",
        "credential": "CRNA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2016-09-29",
        "last_updated": "2018-10-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "MS",
            "license": "901448",
            "primary": true
        },
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "AL",
            "license": "111055",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Goldsboro, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 2, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.