Provider Demographics
NPI:1710113139
Name:MOYSTON, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MOYSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 98TH PL
Mailing Address - Street 2:1
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-3005
Mailing Address - Country:US
Mailing Address - Phone:718-760-2434
Mailing Address - Fax:
Practice Address - Street 1:5525 98TH PL
Practice Address - Street 2:1
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-3005
Practice Address - Country:US
Practice Address - Phone:718-760-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293875164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse