Provider Demographics
NPI:1407917206
Name:MUSCOLINO, STACEY A (PNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:MUSCOLINO
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 KILLOE RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9094
Mailing Address - Country:US
Mailing Address - Phone:315-635-0008
Mailing Address - Fax:
Practice Address - Street 1:151 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2552
Practice Address - Country:US
Practice Address - Phone:315-469-8191
Practice Address - Fax:315-469-4482
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381140-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics