Provider Demographics
NPI:1790200459
Name:SANICOLA, STACY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SANICOLA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 GERVIL ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-4230
Mailing Address - Country:US
Mailing Address - Phone:917-295-3957
Mailing Address - Fax:
Practice Address - Street 1:477 PHILIP AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5818
Practice Address - Country:US
Practice Address - Phone:917-295-3957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342171363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily