Provider Demographics
NPI:1407156045
Name:STALICA, AMY MARIE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:STALICA
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 1:50 S FISHER RD APT C5
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-3613
Mailing Address - Country:US
Mailing Address - Phone:716-512-4650
Mailing Address - Fax:
Practice Address - Street 1:2560 WALDEN AVE
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4757
Practice Address - Country:US
Practice Address - Phone:716-683-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280409-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse