Provider Demographics
NPI:1104848027
Name:CRILLY, STACY ANNE (NP)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:ANNE
Last Name:CRILLY
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 1:55 HORIZON DR.
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-920-8088
Mailing Address - Fax:631-920-8166
Practice Address - Street 1:55 HORIZON DR.
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-920-8088
Practice Address - Fax:631-920-8166
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22618671163W00000X
NY401750363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse