Provider Demographics
NPI:1790060325
Name:BROWN, STACY MADDONNA
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MADDONNA
Last Name:BROWN
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 1:37 PARK AVE
Mailing Address - Street 2:APT C
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-3170
Mailing Address - Country:US
Mailing Address - Phone:631-841-6038
Mailing Address - Fax:
Practice Address - Street 1:37 PARK AVE UNIT C
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-3170
Practice Address - Country:US
Practice Address - Phone:631-578-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307192-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse