Provider Demographics
NPI:1427583111
Name:RYAN, STACEY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1707
Mailing Address - Country:US
Mailing Address - Phone:315-393-3072
Mailing Address - Fax:
Practice Address - Street 1:221 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1707
Practice Address - Country:US
Practice Address - Phone:315-393-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY715179163WP0808X
CT129325163WP0808X
NYF402278-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health