Healthcare Provider Details

I. General information

NPI: 1487243630
Provider Name (Legal Business Name): MARYGRACE THERESE HAYDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARYGRACE THERESE STARK

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7192 N MAIN ST
CLARKSTON MI
48346-1571
US

IV. Provider business mailing address

7192 N MAIN ST
CLARKSTON MI
48346-1571
US

V. Phone/Fax

Practice location:
  • Phone: 248-384-8600
  • Fax: 248-625-0239
Mailing address:
  • Phone: 248-384-8600
  • Fax: 248-625-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010659
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: