Provider Demographics
NPI:1295209179
Name:DORSEY, STACEY L
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:DORSEY
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 1:557 W 150TH ST APT 54
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-2600
Mailing Address - Country:US
Mailing Address - Phone:917-991-3405
Mailing Address - Fax:
Practice Address - Street 1:529 COURTLANDT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5007
Practice Address - Country:US
Practice Address - Phone:718-993-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker