Provider Demographics
NPI:1265709513
Name:SOPER, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SOPER
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 1:19 HODSKIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1175
Mailing Address - Country:US
Mailing Address - Phone:315-379-1445
Mailing Address - Fax:
Practice Address - Street 1:19 HODSKIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1175
Practice Address - Country:US
Practice Address - Phone:315-379-1445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290221164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse