Provider Demographics
NPI:1780235507
Name:NYLAND, STACEY MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MARIE
Last Name:NYLAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:MARIE
Other - Last Name:CILLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 215
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5400
Mailing Address - Country:US
Mailing Address - Phone:248-236-5040
Mailing Address - Fax:248-620-3379
Practice Address - Street 1:5701 BOW POINTE DR STE 215
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5400
Practice Address - Country:US
Practice Address - Phone:248-236-5040
Practice Address - Fax:248-620-3379
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant