Provider Demographics
NPI:1851686448
Name:DEVRIES, STACEY L (CRNA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:DEVRIES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:FLEGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4100 PARK FOREST DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7331
Mailing Address - Country:US
Mailing Address - Phone:231-935-5770
Mailing Address - Fax:231-935-0747
Practice Address - Street 1:4100 PARK FOREST DR
Practice Address - Street 2:SUITE 210
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7331
Practice Address - Country:US
Practice Address - Phone:231-935-5770
Practice Address - Fax:231-935-0747
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230441163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1851686448Medicaid
MI1851686448Medicaid