Healthcare Provider Details

I. General information

NPI: 1316378862
Provider Name (Legal Business Name): STACY BAKER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 LANSING AVE
JACKSON MI
49202-1621
US

IV. Provider business mailing address

3300 LANSING AVE
JACKSON MI
49202-1621
US

V. Phone/Fax

Practice location:
  • Phone: 517-784-2929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703098590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: