Healthcare Provider Details

I. General information

NPI: 1649821729
Provider Name (Legal Business Name): STEPHANIE HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6223 N CANTON CENTER RD STE 201
CANTON MI
48187-2696
US

IV. Provider business mailing address

6223 N CANTON ST SUITE 201
CANTON MI
48187
US

V. Phone/Fax

Practice location:
  • Phone: 734-844-6533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704277196
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: