Provider Demographics
NPI:1710622675
Name:ANGELA STATHOPOULOS
Entity Type:Organization
Organization Name:ANGELA STATHOPOULOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-347-4848
Mailing Address - Street 1:4084 OKEMOS RD STE A
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3258
Mailing Address - Country:US
Mailing Address - Phone:517-347-4848
Mailing Address - Fax:517-347-4844
Practice Address - Street 1:4084 OKEMOS RD STE A
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3258
Practice Address - Country:US
Practice Address - Phone:517-347-4848
Practice Address - Fax:517-347-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704235236OtherSTATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS