Healthcare Provider Details

I. General information

NPI: 1457043077
Provider Name (Legal Business Name): NICOLE STACY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

IHA HOSPITAL MEDICINE SERVICES 5301 MCAULEY DRIVE
YPSILANTI MI
48197
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DRIVE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-8676
  • Fax: 517-205-5968
Mailing address:
  • Phone: 517-205-4750
  • Fax: 517-205-5968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704346507
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: