Provider Demographics
NPI:1093822058
Name:WHITAKER, STEPHANIE K (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:K
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18101 OAKWOOD BLVD
Mailing Address - Street 2:ANESTHESIA DEPT
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4089
Mailing Address - Country:US
Mailing Address - Phone:313-593-7820
Mailing Address - Fax:313-593-8894
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-593-7820
Practice Address - Fax:313-593-8894
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704212002367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4695963Medicaid
MI4695963Medicaid
MIP00307747Medicare ID - Type UnspecifiedRAILROAD MEDICARE