Provider Demographics
NPI:1346585742
Name:WINK, STACEY M (MS)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:M
Last Name:WINK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 OLD NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1607
Mailing Address - Country:US
Mailing Address - Phone:516-484-8434
Mailing Address - Fax:
Practice Address - Street 1:1127 OLD NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1607
Practice Address - Country:US
Practice Address - Phone:516-484-8434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY604836121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist