Provider Demographics
NPI:1659904084
Name:MEAD, STEPHANIE JEAN (RN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEAN
Last Name:MEAD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 ROUTE 146 STE 101
Mailing Address - Street 2:
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3239
Mailing Address - Country:US
Mailing Address - Phone:518-373-3924
Mailing Address - Fax:
Practice Address - Street 1:400 PATROON CREEK BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-5013
Practice Address - Country:US
Practice Address - Phone:518-489-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY612322163W00000X
NY309596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05959645Medicaid