Provider Demographics
NPI:1710729918
Name:MALDONADO-DIAZ, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MALDONADO-DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58565 WESTMOORE CIR
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48048-3412
Mailing Address - Country:US
Mailing Address - Phone:248-410-5665
Mailing Address - Fax:
Practice Address - Street 1:58565 WESTMOORE CIR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MI
Practice Address - Zip Code:48048-3412
Practice Address - Country:US
Practice Address - Phone:248-410-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313637163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant