Provider Demographics
NPI:1003656489
Name:ANDERSON, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ANDERSON
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 1:114 MILL RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12526-5412
Mailing Address - Country:US
Mailing Address - Phone:518-929-8822
Mailing Address - Fax:
Practice Address - Street 1:114 MILL RD, GERMANTOWN, NY 12526, USA
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:NY
Practice Address - Zip Code:12526
Practice Address - Country:US
Practice Address - Phone:518-929-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYL-311166163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant