Healthcare Provider Details

I. General information

NPI: 1558265488
Provider Name (Legal Business Name): STACY MARTELL SWIMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N DORT HWY
FLINT MI
48506-2941
US

IV. Provider business mailing address

3101 MENOMINEE AVE
FLINT MI
48507-1903
US

V. Phone/Fax

Practice location:
  • Phone: 810-955-0162
  • Fax:
Mailing address:
  • Phone: 810-955-0162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: