Provider Demographics
NPI:1962837518
Name:CANTOR, STACEY BROOKE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:BROOKE
Last Name:CANTOR
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:BROOKE
Other - Last Name:VICTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 TOWN CENTER DR
Mailing Address - Street 2:203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-655-3227
Mailing Address - Fax:248-655-3237
Practice Address - Street 1:5150 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1001
Practice Address - Country:US
Practice Address - Phone:248-655-3227
Practice Address - Fax:248-655-3237
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14865-NP363LF0000X
MI4704279344363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner