Basic Information
| Provider Information | |||||||||
| NPI: | 1205297876 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEITLER | ||||||||
| FirstName: | STACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2205 JOLLY RD STE B | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173474085 | ||||||||
| FaxNumber: | 5173474170 | ||||||||
| Practice Location | |||||||||
| Address1: | 36123 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347936140 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2016 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704235508 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1205297876 | 05 | MI | MEDICAID |