Provider Demographics
NPI:1710288741
Name:LIVERMORE-HALE, STEPHANIE NICOLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:LIVERMORE-HALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICOLE
Other - Last Name:LIVERMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8493 POOLS BROOK RD
Mailing Address - Street 2:
Mailing Address - City:KIRKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13082-9503
Mailing Address - Country:US
Mailing Address - Phone:315-271-4325
Mailing Address - Fax:
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215
Practice Address - Country:US
Practice Address - Phone:315-492-5011
Practice Address - Fax:315-492-5320
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014286363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant