Provider Demographics
NPI:1588811988
Name:SPEICHER, STACY ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ELIZABETH
Last Name:SPEICHER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ELIZABETH
Other - Last Name:MELLONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-475-3999
Mailing Address - Fax:315-470-4014
Practice Address - Street 1:475 IRVING AVE
Practice Address - Street 2:SUITE 418
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1756
Practice Address - Country:US
Practice Address - Phone:315-475-3999
Practice Address - Fax:315-470-4014
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY012955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant