Provider Demographics
NPI:1861814220
Name:MASTRACCI, JEANNA
Entity Type:Individual
Prefix:
First Name:JEANNA
Middle Name:
Last Name:MASTRACCI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44344 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1038
Mailing Address - Country:US
Mailing Address - Phone:586-262-5060
Mailing Address - Fax:
Practice Address - Street 1:44344 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1038
Practice Address - Country:US
Practice Address - Phone:586-262-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-19
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704275270363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology