Provider Demographics
NPI:1932715778
Name:STACY, CAROLE A (RN)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:A
Last Name:STACY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10425 RIVER ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:DIMONDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48821-8781
Mailing Address - Country:US
Mailing Address - Phone:517-331-8668
Mailing Address - Fax:
Practice Address - Street 1:2025 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-0828
Practice Address - Country:US
Practice Address - Phone:888-686-0749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704080504163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)