Provider Demographics
NPI:1356685234
Name:AUSTIN, STACIA
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:
Last Name:AUSTIN
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:WADDINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:13694
Mailing Address - Country:US
Mailing Address - Phone:315-388-7703
Mailing Address - Fax:315-388-4707
Practice Address - Street 1:10 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WADDINGTON
Practice Address - State:NY
Practice Address - Zip Code:13694
Practice Address - Country:US
Practice Address - Phone:315-388-7703
Practice Address - Fax:315-388-4707
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY453116101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist