Provider Demographics
NPI:1356751242
Name:SCOTT, STACY R (NP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:R
Last Name:SCOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:WILLIAM BEAUMONT HOSPITAL
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230
Practice Address - Country:US
Practice Address - Phone:313-473-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230848363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner