Provider Demographics
NPI:1659630507
Name:STETZ, SHARON PERSICO
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:PERSICO
Last Name:STETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHARON
Other - Middle Name:
Other - Last Name:PERSICO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:2960 CAMINO DIABLO STE 105
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3945
Practice Address - Country:US
Practice Address - Phone:800-892-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMS5231143363L00000X
MI4704174307363L00000X, 363LP0808X
WAAP61007030363LP0808X
CANP95010824363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner