Provider Demographics
NPI:1134464167
Name:WELCH, STEPHANIE C (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:C
Last Name:WELCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 CLEVELAND AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9670
Mailing Address - Country:US
Mailing Address - Phone:269-439-6604
Mailing Address - Fax:269-429-1715
Practice Address - Street 1:5515 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9670
Practice Address - Country:US
Practice Address - Phone:269-429-6604
Practice Address - Fax:269-429-1715
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI56101006545208000000X
MI5601006545363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134464167Medicaid
MI1134464167Medicaid