Provider Demographics
NPI:1447453402
Name:MYRACLE, STEPHANIE D (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:D
Last Name:MYRACLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:DIAMANTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:89 HOSPITAL DR STE A-UP1
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-4837
Mailing Address - Country:US
Mailing Address - Phone:828-570-5505
Mailing Address - Fax:828-259-2581
Practice Address - Street 1:89 HOSPITAL DR STE A-UP1
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-4837
Practice Address - Country:US
Practice Address - Phone:828-570-5505
Practice Address - Fax:828-259-2581
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01974207N00000X, 207NS0135X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918699Medicaid
NCNC1588BMedicare PIN