Healthcare Provider Details

I. General information

NPI: 1386975084
Provider Name (Legal Business Name): MRS. STEPHANIE ARLENE MAYNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 SYLVAN AVE SE
GRAND RAPIDS MI
49506-3934
US

IV. Provider business mailing address

1229 SYLVAN AVE SE
GRAND RAPIDS MI
49506-3934
US

V. Phone/Fax

Practice location:
  • Phone: 616-706-1040
  • Fax: 616-248-8688
Mailing address:
  • Phone: 616-706-1040
  • Fax: 616-248-8688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: