Provider Demographics
NPI:1992194047
Name:MUNN, STACEY (RN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MUNN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4905
Mailing Address - Country:US
Mailing Address - Phone:516-514-4061
Mailing Address - Fax:
Practice Address - Street 1:141 CEDAR ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4905
Practice Address - Country:US
Practice Address - Phone:516-514-4061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY604632-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse