Provider Demographics
NPI:1336837202
Name:BENNETT, STACY N (CRPA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:N
Last Name:BENNETT
Suffix:
Gender:M
Credentials:CRPA
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:N
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 E 165TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-6073
Mailing Address - Country:US
Mailing Address - Phone:718-790-5889
Mailing Address - Fax:
Practice Address - Street 1:304 E 165TH ST APT 4
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-6073
Practice Address - Country:US
Practice Address - Phone:718-790-5889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5652175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist