Provider Demographics
NPI:1114684057
Name:PERSAUD, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PERSAUD
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 1:19 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WHEATLEY HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11798-1005
Mailing Address - Country:US
Mailing Address - Phone:631-276-5360
Mailing Address - Fax:
Practice Address - Street 1:19 BROOKWOOD DR
Practice Address - Street 2:
Practice Address - City:WHEATLEY HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11798-1005
Practice Address - Country:US
Practice Address - Phone:631-276-5360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-28
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321021164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse