Provider Demographics
NPI:1114202504
Name:BURT, STACEY A (RN)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:A
Last Name:BURT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:RIDDLEBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1376 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-5702
Mailing Address - Country:US
Mailing Address - Phone:607-821-8739
Mailing Address - Fax:
Practice Address - Street 1:1376 RIVER RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-5702
Practice Address - Country:US
Practice Address - Phone:607-821-8739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402391-1163WH0200X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1115202504Medicaid