Provider Demographics
NPI:1770832966
Name:STEPHENS-MACK, QUIANA LYNELL (MSN CPNP)
Entity Type:Individual
Prefix:
First Name:QUIANA
Middle Name:LYNELL
Last Name:STEPHENS-MACK
Suffix:
Gender:F
Credentials:MSN CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22475 CULPEPER DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4245
Mailing Address - Country:US
Mailing Address - Phone:313-549-7406
Mailing Address - Fax:
Practice Address - Street 1:12800 KELLY RD
Practice Address - Street 2:ST JOHN HEALTH CENTER, RM 102B
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1506
Practice Address - Country:US
Practice Address - Phone:313-372-3826
Practice Address - Fax:313-372-3990
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704245159363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164553099Medicaid
MI5008721450OtherBC IND PIN