Provider Demographics
NPI:1184749053
Name:CEDENO, STACEY (ANP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CEDENO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 NESCONSET HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-265-9111
Mailing Address - Fax:631-265-7363
Practice Address - Street 1:496 SMITHTOWN BYP
Practice Address - Street 2:SUITE 200
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5005
Practice Address - Country:US
Practice Address - Phone:631-265-9111
Practice Address - Fax:631-265-7363
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304048363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health