Healthcare Provider Details

I. General information

NPI: 1053599449
Provider Name (Legal Business Name): NICOLE MARIE STANCZAK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31157 WOODWARD AVE
ROYAL OAK MI
48073-0996
US

IV. Provider business mailing address

31157 WOODWARD AVE
ROYAL OAK MI
48073-0996
DE

V. Phone/Fax

Practice location:
  • Phone: 248-336-0123
  • Fax: 248-336-3190
Mailing address:
  • Phone: 248-336-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704212050
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: