Healthcare Provider Details

I. General information

NPI: 1407999824
Provider Name (Legal Business Name): STEFANIE LEA CLUTTEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 S PENNSYLVANIA AVE STE 204
LANSING MI
48910-3496
US

IV. Provider business mailing address

3394 E JOLLY RD SUITE C
LANSING MI
48910-8594
US

V. Phone/Fax

Practice location:
  • Phone: 517-267-0200
  • Fax:
Mailing address:
  • Phone: 517-272-9700
  • Fax: 517-272-9706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: