Provider Demographics
NPI:1912476359
Name:DUKE, STACY-ANNE JESELLE
Entity Type:Individual
Prefix:MISS
First Name:STACY-ANNE
Middle Name:JESELLE
Last Name:DUKE
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 1:1395 EXETER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1306
Mailing Address - Country:US
Mailing Address - Phone:917-622-8089
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308638-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health