Provider Demographics
NPI:1275844136
Name:STACEY, DEBRA (MSNE PMHNP ANP CDE)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:STACEY
Suffix:
Gender:F
Credentials:MSNE PMHNP ANP CDE
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:MADISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3843 UNION RD # 15-127
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4256
Mailing Address - Country:US
Mailing Address - Phone:716-544-0996
Mailing Address - Fax:716-544-0997
Practice Address - Street 1:5820 MAIN ST STE 406
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5734
Practice Address - Country:US
Practice Address - Phone:716-544-0996
Practice Address - Fax:716-544-0997
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY486617-1163WD0400X
NY401660363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator