Provider Demographics
NPI:1871019356
Name:STANTON, AVERY
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:STANTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-1337
Mailing Address - Country:US
Mailing Address - Phone:315-729-1374
Mailing Address - Fax:
Practice Address - Street 1:139 HORIZON DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-1337
Practice Address - Country:US
Practice Address - Phone:315-729-1374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329647164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty