Provider Demographics
NPI:1316581267
Name:STALEY PSYCHIATRIC NURSE PRACTITIONER PLLC
Entity Type:Organization
Organization Name:STALEY PSYCHIATRIC NURSE PRACTITIONER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS-STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-470-2245
Mailing Address - Street 1:19605 FOOTHILL AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1413
Mailing Address - Country:US
Mailing Address - Phone:718-470-2245
Mailing Address - Fax:718-470-2245
Practice Address - Street 1:19605 FOOTHILL AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1413
Practice Address - Country:US
Practice Address - Phone:718-470-2245
Practice Address - Fax:718-470-2245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty