Provider Demographics
NPI:1962874156
Name:JUNIOR, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:JUNIOR
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 1:94 E HENRY ST
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218-1640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 E HENRY ST
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1640
Practice Address - Country:US
Practice Address - Phone:313-300-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider