Provider Demographics
NPI:1750743746
Name:STACKHOUSE, CARLETTA (MS, ANP)
Entity type:Individual
Prefix:MS
First Name:CARLETTA
Middle Name:
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:MS, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 HEMPSTEAD AVENUE
Mailing Address - Street 2:PO BOX 328
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-0328
Mailing Address - Country:US
Mailing Address - Phone:516-253-0035
Mailing Address - Fax:
Practice Address - Street 1:40 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-1830
Practice Address - Country:US
Practice Address - Phone:516-253-0035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY524609163WH0200X
NY307783363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health