Provider Demographics
NPI:1902211121
Name:MIKULSKI, STEPHANIE HASTY (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:HASTY
Last Name:MIKULSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44555 WOODWARD AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5035
Mailing Address - Country:US
Mailing Address - Phone:248-858-3949
Mailing Address - Fax:248-858-3929
Practice Address - Street 1:44555 WOODWARD AVE STE 302
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5035
Practice Address - Country:US
Practice Address - Phone:586-745-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021146208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation