Provider Demographics
NPI:1356678866
Name:REA, STEPHANIE A (PAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:REA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:A
Other - Last Name:MANDUZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:8338 ALLEN ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101
Mailing Address - Country:US
Mailing Address - Phone:313-386-5500
Mailing Address - Fax:313-386-1339
Practice Address - Street 1:8338 ALLEN ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101
Practice Address - Country:US
Practice Address - Phone:313-386-5500
Practice Address - Fax:313-386-1339
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005671207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005671OtherST LISC