Provider Demographics
NPI:1356022560
Name:HUMBERT, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:HUMBERT
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 1:3605 LAKES CORNERS ROSE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NY
Mailing Address - Zip Code:14433-9606
Mailing Address - Country:US
Mailing Address - Phone:315-521-9228
Mailing Address - Fax:
Practice Address - Street 1:367 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1662
Practice Address - Country:US
Practice Address - Phone:315-521-9228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF351974-01363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care