Provider Demographics
NPI:1154868644
Name:STOVALL, TANYA
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:
Last Name:STOVALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:STOVALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23330 OAK GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3491
Mailing Address - Country:US
Mailing Address - Phone:877-436-4636
Mailing Address - Fax:877-436-4636
Practice Address - Street 1:23330 OAK GLEN DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-3491
Practice Address - Country:US
Practice Address - Phone:877-436-4636
Practice Address - Fax:877-436-4636
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246RP1900X, 2472E0500X
MI23D2176188291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG