Provider Demographics
NPI:1689399420
Name:STAPLES, PRINCESS
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:
Last Name:STAPLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 E NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-1254
Mailing Address - Country:US
Mailing Address - Phone:313-320-9199
Mailing Address - Fax:
Practice Address - Street 1:21 E NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1254
Practice Address - Country:US
Practice Address - Phone:248-579-5775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator