Healthcare Provider Details

I. General information

NPI: 1134464167
Provider Name (Legal Business Name): STEPHANIE C WELCH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5515 CLEVELAND AVE
STEVENSVILLE MI
49127-9670
US

IV. Provider business mailing address

5515 CLEVELAND AVE SUITE 2
STEVENSVILLE MI
49127-9670
US

V. Phone/Fax

Practice location:
  • Phone: 269-429-6604
  • Fax: 269-429-1715
Mailing address:
  • Phone: 269-439-6604
  • Fax: 269-429-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56101006545
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601006545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: