Provider Demographics
NPI:1639347065
Name:STOUDEMIRE, DARLEEN KAY (OPTICIAN)
Entity type:Individual
Prefix:
First Name:DARLEEN
Middle Name:KAY
Last Name:STOUDEMIRE
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 TOWN LINE RD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-4549
Mailing Address - Country:US
Mailing Address - Phone:315-592-9166
Mailing Address - Fax:
Practice Address - Street 1:2901 COURT ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-3217
Practice Address - Country:US
Practice Address - Phone:315-455-8933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005835-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician