Provider Demographics
NPI:1871319053
Name:STEVENS, CODY AUSTIN
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:AUSTIN
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 STRIBLING ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3343
Mailing Address - Country:US
Mailing Address - Phone:601-416-6348
Mailing Address - Fax:
Practice Address - Street 1:1314 19TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4116
Practice Address - Country:US
Practice Address - Phone:601-483-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS909737163W00000X
MS901955367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse