Healthcare Provider Details

I. General information

NPI: 1174210124
Provider Name (Legal Business Name): GARY MICHAEL STEPHENS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 SHAFFER ST
KALAMAZOO MI
49048-1604
US

IV. Provider business mailing address

126 EATON ST
BATTLE CREEK MI
49017-5444
US

V. Phone/Fax

Practice location:
  • Phone: 269-382-9820
  • Fax:
Mailing address:
  • Phone: 269-274-4496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704307723
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: