Provider Demographics
NPI:1093222036
Name:OVERTON, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:OVERTON
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 1:1890 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-4453
Mailing Address - Country:US
Mailing Address - Phone:631-369-9055
Mailing Address - Fax:631-727-2137
Practice Address - Street 1:1890 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-4453
Practice Address - Country:US
Practice Address - Phone:631-369-9055
Practice Address - Fax:631-727-2137
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9957156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician