Basic Information
| Provider Information | |||||||||
| NPI: | 1689075020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | CHANTA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 TOWN CENTER DR | ||||||||
| Address2: | 203 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480841744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485858265 | ||||||||
| FaxNumber: | 2485858266 | ||||||||
| Practice Location | |||||||||
| Address1: | 27901 WOODWARD AVE | ||||||||
| Address2: | 300 | ||||||||
| City: | BERKLEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480720919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485450070 | ||||||||
| FaxNumber: | 2485454580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2014 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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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 | 163W00000X | 4704281365 | MI | N | Nursing Service Providers | Registered Nurse | 363L00000X | 4704281365 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.