Healthcare Provider Details

I. General information

NPI: 1194139527
Provider Name (Legal Business Name): STACEY BONECUTTER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 E PARKDALE AVE STE 3
MANISTEE MI
49660-9364
US

IV. Provider business mailing address

1806 E PARKDALE AVE STE 3
MANISTEE MI
49660-9364
US

V. Phone/Fax

Practice location:
  • Phone: 231-398-9536
  • Fax: 231-398-9541
Mailing address:
  • Phone: 231-398-9536
  • Fax: 231-398-9541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704217372
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: