Provider Demographics
NPI:1821140443
Name:KREISWIRTH, STACY J (NP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:J
Last Name:KREISWIRTH
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 1:67 IRVING PLACE #5FL
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:212-253-2968
Mailing Address - Fax:212-253-2925
Practice Address - Street 1:67 IRVING PLACE #5FL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-253-2968
Practice Address - Fax:212-253-2925
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300560363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01736209Medicaid
NY007591Medicare ID - Type Unspecified
NY01736209Medicaid