Provider Demographics
NPI:1407815046
Name:STALLONE, JUDITH ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANN
Last Name:STALLONE
Suffix:
Gender:F
Credentials:NP
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 1019
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-0819
Mailing Address - Country:US
Mailing Address - Phone:631-351-4101
Mailing Address - Fax:
Practice Address - Street 1:270 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2787
Practice Address - Country:US
Practice Address - Phone:631-351-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400356-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q11323Medicare UPIN
NY0481G1Medicare ID - Type Unspecified