Provider Demographics
NPI:1518904614
Name:STAYTON, HOLLI (FNP)
Entity type:Individual
Prefix:
First Name:HOLLI
Middle Name:
Last Name:STAYTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:HOLLI
Other - Middle Name:
Other - Last Name:STANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:UNITED HEALTH SERVICES HOSP INC
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:9 OGDEN ST
Practice Address - Street 2:ROOSEVELT SCHOOL BASED CLINIC
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901
Practice Address - Country:US
Practice Address - Phone:607-762-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333114363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02328765Medicaid
P13074Medicare UPIN
NYCC1710Medicare PIN