Provider Demographics
NPI:1174629778
Name:BIRDSALL, STACIA BETH (CNM)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:BETH
Last Name:BIRDSALL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WALKER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4135
Mailing Address - Country:US
Mailing Address - Phone:212-226-8866
Mailing Address - Fax:212-226-2289
Practice Address - Street 1:268 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3599
Practice Address - Country:US
Practice Address - Phone:212-966-0228
Practice Address - Fax:212-966-9330
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001385-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03338112Medicaid