Provider Demographics
NPI:1013187616
Name:POMINVILLE, STACY L (NP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:POMINVILLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:BANGMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:10 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-1590
Mailing Address - Country:US
Mailing Address - Phone:508-248-3015
Mailing Address - Fax:508-248-4734
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507-1590
Practice Address - Country:US
Practice Address - Phone:508-248-3015
Practice Address - Fax:508-248-4734
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA266669363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000495601Medicare PIN
MA000495602Medicare PIN