Provider Demographics
NPI:1780051839
Name:CATTANEO, STACI SUE
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:SUE
Last Name:CATTANEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:SUE
Other - Last Name:KRIEBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 E MICHIGAN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1852
Mailing Address - Country:US
Mailing Address - Phone:517-780-7224
Mailing Address - Fax:
Practice Address - Street 1:1201 E MICHIGAN AVE
Practice Address - Street 2:STE 100
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1852
Practice Address - Country:US
Practice Address - Phone:517-780-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704288888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily