1689075020 NPI number — CHANTA L. STANLEY NP-C

Table of content: CHANTA L. STANLEY NP-C (NPI 1689075020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689075020 NPI number — CHANTA L. STANLEY NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANLEY
Provider First Name:
CHANTA
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689075020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 TOWN CENTER DR
Provider Second Line Business Mailing Address:
203
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48084-1744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-585-8265
Provider Business Mailing Address Fax Number:
248-585-8266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27901 WOODWARD AVE
Provider Second Line Business Practice Location Address:
300
Provider Business Practice Location Address City Name:
BERKLEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48072-0919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-545-0070
Provider Business Practice Location Address Fax Number:
248-545-4580
Provider Enumeration Date:
09/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  4704281365 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 4704281365 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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