Provider Demographics
NPI:1467866483
Name:GREENE, STACY (IBCLC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 CORTELYOU RD APT 4E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-6300
Mailing Address - Country:US
Mailing Address - Phone:917-882-7590
Mailing Address - Fax:
Practice Address - Street 1:811 CORTELYOU RD APT 4E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-6300
Practice Address - Country:US
Practice Address - Phone:917-882-7590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYL-49909174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN