Provider Demographics
NPI:1205171212
Name:BISHOFF, STACY LYN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYN
Last Name:BISHOFF
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 1:11622 SCOTCH RD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:NY
Mailing Address - Zip Code:14065-9770
Mailing Address - Country:US
Mailing Address - Phone:716-492-0492
Mailing Address - Fax:
Practice Address - Street 1:11622 SCOTCH RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:NY
Practice Address - Zip Code:14065-9770
Practice Address - Country:US
Practice Address - Phone:716-492-0492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-02
Last Update Date:2012-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004379-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker