Provider Demographics
NPI:1841851821
Name:NULTY, STEPHANIE (MD, MBA)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:NULTY
Suffix:
Gender:F
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14128
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4032
Mailing Address - Country:US
Mailing Address - Phone:248-680-8000
Mailing Address - Fax:
Practice Address - Street 1:26850 PROVIDENCE PKWY STE 260
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1256
Practice Address - Country:US
Practice Address - Phone:248-465-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301513789207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program