Provider Demographics
NPI:1295498491
Name:BLOSSEY, STEPHANIE ANN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:BLOSSEY
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 1:505 FRASER ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-7124
Mailing Address - Country:US
Mailing Address - Phone:989-482-6927
Mailing Address - Fax:989-509-5900
Practice Address - Street 1:316 FITZHUGH ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7159
Practice Address - Country:US
Practice Address - Phone:989-316-1758
Practice Address - Fax:989-509-5900
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS0904077313104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness