Provider Demographics
NPI:1942463120
Name:COOL, STACEY A
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:A
Last Name:COOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 ST HIGHWAY 331
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13452-2818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:136 ST HIGHWAY 331
Practice Address - Street 2:
Practice Address - City:ST JOHNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13452-2818
Practice Address - Country:US
Practice Address - Phone:518-568-5960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10282261164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10282261Medicaid