Provider Demographics
NPI:1053791194
Name:DOSENBERRY, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:DOSENBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7915 W CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:MI
Mailing Address - Zip Code:49269-9534
Mailing Address - Country:US
Mailing Address - Phone:517-531-0004
Mailing Address - Fax:
Practice Address - Street 1:7915 W CIRCLE DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:MI
Practice Address - Zip Code:49269-9534
Practice Address - Country:US
Practice Address - Phone:517-531-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703106851164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse