Healthcare Provider Details

I. General information

NPI: 1164159059
Provider Name (Legal Business Name): TAMMIE L KELLEY STAHR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S RAISINVILLE RD
MONROE MI
48161-9754
US

IV. Provider business mailing address

2700 LACKAWANNA AVE LOT 12
BLOOMSBURG PA
17815-3201
US

V. Phone/Fax

Practice location:
  • Phone: 734-243-7340
  • Fax:
Mailing address:
  • Phone: 570-204-2809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number4704392600
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN616419
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN616419
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: