Provider Demographics
NPI:1912443011
Name:GISSAL, STACY (LPN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GISSAL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 WOODWARD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0960
Mailing Address - Country:US
Mailing Address - Phone:248-395-3777
Mailing Address - Fax:
Practice Address - Street 1:28000 WOODWARD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0960
Practice Address - Country:US
Practice Address - Phone:248-395-3777
Practice Address - Fax:248-395-3370
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703107589164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse