Provider Demographics
NPI:1467631754
Name:SHORETTE, STACY C S (LPN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:C S
Last Name:SHORETTE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SAUGERTIES
Mailing Address - State:NY
Mailing Address - Zip Code:12477
Mailing Address - Country:US
Mailing Address - Phone:845-247-3248
Mailing Address - Fax:
Practice Address - Street 1:1173 CHURCH RD
Practice Address - Street 2:
Practice Address - City:SAUGERTIES
Practice Address - State:NY
Practice Address - Zip Code:12477-3236
Practice Address - Country:US
Practice Address - Phone:845-247-3248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245193164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02880573Medicaid