Basic Information
| Provider Information | |||||||||
| NPI: | 1437896115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STUART | ||||||||
| FirstName: | MIKAYLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PISANE | ||||||||
| OtherFirstName: | MIKAYLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 727 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | ALGONAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480011558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869604017 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3104 KING RD | ||||||||
| Address2: | |||||||||
| City: | CHINA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480541428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103284500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2022 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.