Provider Demographics
NPI:1821105743
Name:STAHLECKER-ETTER, MARYANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:STAHLECKER-ETTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX MED
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-2901
Mailing Address - Fax:585-273-1288
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX MED
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-8762
Practice Address - Fax:585-273-1288
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY302821363LA2200X
NYF302821-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB7816Medicare PIN
NYP23919Medicare UPIN