Provider Demographics
NPI:1184893497
Name:STACOM, RACHAEL MARY (ANP)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:MARY
Last Name:STACOM
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 1:37 E 83RD ST
Mailing Address - Street 2:APT 1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0813
Mailing Address - Country:US
Mailing Address - Phone:212-744-6731
Mailing Address - Fax:212-995-5016
Practice Address - Street 1:1770 GRAND CONCOURSE
Practice Address - Street 2:SUITE 2G
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-5524
Practice Address - Country:US
Practice Address - Phone:718-393-7617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304736363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health