Provider Demographics
NPI:1487035739
Name:STANTON, MARYLOU (FNP)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:STANTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-1019
Mailing Address - Country:US
Mailing Address - Phone:607-337-4111
Mailing Address - Fax:607-337-4649
Practice Address - Street 1:179 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1019
Practice Address - Country:US
Practice Address - Phone:607-337-4111
Practice Address - Fax:607-337-4649
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY15-0532180OtherTAX IDENTIFICATION NUMBER