Provider Demographics
NPI:1245386317
Name:PENDELL, STACEY A (PNP-BC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:PENDELL
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:A
Other - Last Name:STALTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNC
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-762-2468
Mailing Address - Fax:607-762-3871
Practice Address - Street 1:10 - 42 MITCHELL AVENUE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903
Practice Address - Country:US
Practice Address - Phone:607-762-2468
Practice Address - Fax:607-762-3871
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381553363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03018146Medicaid