Healthcare Provider Details

I. General information

NPI: 1699343566
Provider Name (Legal Business Name): TRACY STANISH DNP, RN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N JACKSON ST FL 1
JACKSON MI
49201-1266
US

IV. Provider business mailing address

505 N JACKSON ST
JACKSON MI
49201-1266
US

V. Phone/Fax

Practice location:
  • Phone: 517-748-5500
  • Fax:
Mailing address:
  • Phone: 517-748-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704220747
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704220747
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: