Provider Demographics
NPI:1538469770
Name:DOUGLAS-STALEY, ANGELA (RN, NP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:DOUGLAS-STALEY
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-3609
Mailing Address - Country:US
Mailing Address - Phone:646-528-7246
Mailing Address - Fax:
Practice Address - Street 1:2369 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3108
Practice Address - Country:US
Practice Address - Phone:212-876-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401312-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1538469770Medicare UPIN