Provider Demographics
NPI:1841698065
Name:HUMPHREYS, STACY M (NPP)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:M
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 PARK AVE
Mailing Address - Street 2:SUITE 3007
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3375 PARK AVE
Practice Address - Street 2:SUITE 3007
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3733
Practice Address - Country:US
Practice Address - Phone:184-438-6583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400954-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health