Healthcare Provider Details

I. General information

NPI: 1043753502
Provider Name (Legal Business Name): STACI DAMIANI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 KINGSWAY CT
TRENTON MI
48183-1958
US

IV. Provider business mailing address

1675 KINGSWAY CT
TRENTON MI
48183-1958
US

V. Phone/Fax

Practice location:
  • Phone: 734-676-8530
  • Fax: 734-676-2319
Mailing address:
  • Phone: 734-676-8530
  • Fax: 734-676-2319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704273650
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: