Provider Demographics
NPI:1841602166
Name:STACK, SAMANTHA MICHELLE
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:STACK
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 1:500 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4224
Mailing Address - Country:US
Mailing Address - Phone:989-272-0204
Mailing Address - Fax:989-797-3477
Practice Address - Street 1:1044 GILBERT ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3527
Practice Address - Country:US
Practice Address - Phone:810-422-7623
Practice Address - Fax:810-733-7623
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703119950164W00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No164W00000XNursing Service ProvidersLicensed Practical Nurse