Provider Demographics
NPI:1972148039
Name:VALLIE, STEPHANIE KAY
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KAY
Last Name:VALLIE
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 1:16451 RED FOX TRL
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-9172
Mailing Address - Country:US
Mailing Address - Phone:810-869-4456
Mailing Address - Fax:
Practice Address - Street 1:303 E KEARSLEY ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1907
Practice Address - Country:US
Practice Address - Phone:810-762-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704325066367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty