=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316596935
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY CATHERINE STAGE RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2019
-----------------------------------------------------
Last Update Date | 09/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2236 E MITCHELL RD STE 5
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-9604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-347-9880
-----------------------------------------------------
Fax | 231-347-9313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2236 E MITCHELL RD STE 5
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-9604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-347-9880
-----------------------------------------------------
Fax | 231-347-9313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 4704212582
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------