Provider Demographics
NPI:1790377331
Name:MARKHAM, STEPHEN GLEN (RN)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GLEN
Last Name:MARKHAM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51350 FORD RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4638
Mailing Address - Country:US
Mailing Address - Phone:734-560-6765
Mailing Address - Fax:
Practice Address - Street 1:51350 FORD RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4638
Practice Address - Country:US
Practice Address - Phone:734-560-6765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704326909163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse