Provider Demographics
NPI:1407212756
Name:KYEA, STACEY (MA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KYEA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:SMOLINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:56 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182-1604
Mailing Address - Country:US
Mailing Address - Phone:518-810-3333
Mailing Address - Fax:
Practice Address - Street 1:56 BISCAYNE BOULEVARD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182-1604
Practice Address - Country:US
Practice Address - Phone:518-496-1553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1135199390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program