Healthcare Provider Details

I. General information

NPI: 1215690458
Provider Name (Legal Business Name): STACEY RENAE COUCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18591 W 10 MILE RD
SOUTHFIELD MI
48075-2619
US

IV. Provider business mailing address

23938 FAIRVIEW CT
FARMINGTON HILLS MI
48335-3117
US

V. Phone/Fax

Practice location:
  • Phone: 248-621-9443
  • Fax: 248-621-9553
Mailing address:
  • Phone: 313-743-2512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704321587
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704321587
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: