Provider Demographics
NPI:1417208463
Name:SMITH, STEPHANIE DORA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DORA
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:DORA
Other - Last Name:POSTMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 CHERRY ST SE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4607
Mailing Address - Country:US
Mailing Address - Phone:616-685-3330
Mailing Address - Fax:
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:SUITE 204
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-685-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-29
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272685363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health