Healthcare Provider Details

I. General information

NPI: 1265080832
Provider Name (Legal Business Name): MICHAEL ELLIS STERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 BARNES ST
PROVIDENCE RI
02906-1502
US

IV. Provider business mailing address

7260 POST RD STE 103
NORTH KINGSTOWN RI
02852-3246
US

V. Phone/Fax

Practice location:
  • Phone: 401-744-6447
  • Fax:
Mailing address:
  • Phone: 401-744-6447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN02134
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: