Healthcare Provider Details

I. General information

NPI: 1780929224
Provider Name (Legal Business Name): STACIE SNADON-FORD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 ROLAND ST
PONTIAC MI
48341-2372
US

IV. Provider business mailing address

461 ROLAND ST
PONTIAC MI
48341-2372
US

V. Phone/Fax

Practice location:
  • Phone: 248-342-2866
  • Fax:
Mailing address:
  • Phone: 248-342-2866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704317802
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703107323
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: