Healthcare Provider Details

I. General information

NPI: 1861066433
Provider Name (Legal Business Name): STACY ANN NOWAK RN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/18/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24230 KARIM BLVD
NOVI MI
48375-2960
US

IV. Provider business mailing address

24230 KARIM BLVD
NOVI MI
48375-2960
US

V. Phone/Fax

Practice location:
  • Phone: 248-745-4900
  • Fax: 248-994-8005
Mailing address:
  • Phone: 248-745-4900
  • Fax: 248-994-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704272127
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: