Provider Demographics
NPI:1174210124
Name:STEPHENS, GARY MICHAEL (RN)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 EATON ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-5444
Mailing Address - Country:US
Mailing Address - Phone:269-274-4496
Mailing Address - Fax:
Practice Address - Street 1:1910 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1604
Practice Address - Country:US
Practice Address - Phone:269-382-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307723163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health