Provider Demographics
NPI:1063860914
Name:TAYLOR, STACEY (FNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE ROAD
Mailing Address - Street 2:SUITE 400 - CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-745-7999
Mailing Address - Fax:313-966-6400
Practice Address - Street 1:4201 SAINT ANTOINE ST STE 5C
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-7999
Practice Address - Fax:313-966-6400
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704246188363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily