Provider Demographics
NPI:1093066250
Name:JUDD, STACY DANIELLE (NP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:DANIELLE
Last Name:JUDD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 PENFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1756
Mailing Address - Country:US
Mailing Address - Phone:585-598-8505
Mailing Address - Fax:
Practice Address - Street 1:2212 PENFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1756
Practice Address - Country:US
Practice Address - Phone:585-598-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349850363LF0000X
NYF349850-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily