Healthcare Provider Details

I. General information

NPI: 1154868644
Provider Name (Legal Business Name): MS. TANYA STOVALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TANYA STOVALL

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23330 OAK GLEN DR
SOUTHFIELD MI
48033-3491
US

IV. Provider business mailing address

23330 OAK GLEN DR
SOUTHFIELD MI
48033-3491
US

V. Phone/Fax

Practice location:
  • Phone: 877-436-4636
  • Fax: 877-436-4636
Mailing address:
  • Phone: 877-436-4636
  • Fax: 877-436-4636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number23D2176188
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: