Healthcare Provider Details

I. General information

NPI: 1972148039
Provider Name (Legal Business Name): STEPHANIE KAY VALLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E KEARSLEY ST
FLINT MI
48502-1907
US

IV. Provider business mailing address

16451 RED FOX TRL
LINDEN MI
48451-9172
US

V. Phone/Fax

Practice location:
  • Phone: 810-762-3300
  • Fax:
Mailing address:
  • Phone: 810-869-4456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704325066
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: