Provider Demographics
NPI:1740232412
Name:MICHAELS, STACEY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LYNN
Last Name:MICHAELS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:37750 S ENTRY RD
Mailing Address - Street 2:
Mailing Address - City:CHASSELL
Mailing Address - State:MI
Mailing Address - Zip Code:49916-9258
Mailing Address - Country:US
Mailing Address - Phone:906-523-1987
Mailing Address - Fax:
Practice Address - Street 1:45070 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:CHASSELL
Practice Address - State:MI
Practice Address - Zip Code:49916-9116
Practice Address - Country:US
Practice Address - Phone:906-481-7652
Practice Address - Fax:906-481-2020
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI003322152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU42112Medicare UPIN