Provider Demographics
NPI:1447250030
Name:ROBERTS, STEPHANIE E (CRNA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:E
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:ELLICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:125 DOUGHTY ST STE 420
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5741
Mailing Address - Country:US
Mailing Address - Phone:843-723-3441
Mailing Address - Fax:843-805-4040
Practice Address - Street 1:316 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1125
Practice Address - Country:US
Practice Address - Phone:843-724-2715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC070448367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1272Medicaid
SCAN1272Medicaid