Provider Demographics
NPI:1114426566
Name:MONTEFUSCO, STACEY (MS, ATC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MONTEFUSCO
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:HERRIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC
Mailing Address - Street 1:157 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:BELFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07718-1514
Mailing Address - Country:US
Mailing Address - Phone:301-535-8944
Mailing Address - Fax:
Practice Address - Street 1:4810 BELMAR BLVD
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-6952
Practice Address - Country:US
Practice Address - Phone:732-938-6090
Practice Address - Fax:732-938-5680
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT00138800207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery