Provider Demographics
NPI:1942535570
Name:CRETELLA, STEFANIE LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:LYNN
Last Name:CRETELLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:STEFANIE
Other - Middle Name:LYNN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 749306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:459 N HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3924
Practice Address - Country:US
Practice Address - Phone:843-899-3870
Practice Address - Fax:843-899-3877
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SC1496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1117PAMedicaid
SCAA62886834Medicare PIN