Provider Demographics
NPI:1811019201
Name:STEDFORD, AUDREY (DNP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:STEDFORD
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 E 102ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-2620
Mailing Address - Country:US
Mailing Address - Phone:646-631-9103
Mailing Address - Fax:
Practice Address - Street 1:2035 RALPH AVE STE A8
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5300
Practice Address - Country:US
Practice Address - Phone:646-631-9103
Practice Address - Fax:347-352-3238
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303562363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04359606Medicaid