Provider Demographics
NPI:1669096707
Name:TITTAMIN, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:TITTAMIN
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 1:24 MONHEGON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-1808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1602
Practice Address - Country:US
Practice Address - Phone:315-440-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR13744500163W00000X
NJ26NJ01041100367500000X
NY740498367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse