Provider Demographics
NPI:1972854792
Name:KACHALLA, STEPHANIE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:KACHALLA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:ROSLONSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:75 BARCLAY CIR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5820
Mailing Address - Country:US
Mailing Address - Phone:248-299-1892
Mailing Address - Fax:
Practice Address - Street 1:75 BARCLAY CIR
Practice Address - Street 2:SUITE 225
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5820
Practice Address - Country:US
Practice Address - Phone:248-299-1892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22383363LA2200X
MI4704253075363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22383OtherCA BOARD OF REGISTERED NURSING
CA22383OtherCA BOARD OF REGISTERED NURSING