Provider Demographics
NPI:1336761907
Name:GEOGHEGAN, STACEY (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:GEOGHEGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 WASHINGTON ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-2507
Mailing Address - Country:US
Mailing Address - Phone:646-357-2209
Mailing Address - Fax:
Practice Address - Street 1:684 WASHINGTON ST APT 3B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-2507
Practice Address - Country:US
Practice Address - Phone:646-357-2209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-17
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309321-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health