Provider Demographics
NPI:1285991356
Name:ILLIAN, STEPHANIE LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:ILLIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16208 BALDWIN CIR
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-9384
Mailing Address - Country:US
Mailing Address - Phone:586-215-3273
Mailing Address - Fax:
Practice Address - Street 1:1 WILLIAM CARLS DR
Practice Address - Street 2:STE 120
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-2201
Practice Address - Country:US
Practice Address - Phone:248-937-4947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006316363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical