Provider Demographics
NPI:1659486041
Name:RIVET, STACEY LYNN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:RIVET
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6794
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:MC 117
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-267-0118
Practice Address - Fax:616-267-0090
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225948363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008772580OtherBLUE CROSS BLUE SHIELD
MI1057817OtherMCLAREN HEALTH PLAN-MEDICAID
MI0N55170019OtherMEDICARE PLUS BLUE
MIP00766372OtherRAILROAD MEDICARE
MI1057817OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI1057817OtherMCLAREN HEALTH ADVANTAGE
MIN55170019Medicare PIN