Provider Demographics
NPI:1407387608
Name:COLES, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:COLES
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 1:155 LINDEN BLVD
Mailing Address - Street 2:1G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-3386
Mailing Address - Country:US
Mailing Address - Phone:347-264-3355
Mailing Address - Fax:
Practice Address - Street 1:155 LINDEN BLVD
Practice Address - Street 2:1G
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3386
Practice Address - Country:US
Practice Address - Phone:347-264-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY726629163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse