Healthcare Provider Details

I. General information

NPI: 1114980729
Provider Name (Legal Business Name): STACEY ANN LAURITO PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HAMILTON HEALTH PL
TRENTON NJ
08690-3542
US

IV. Provider business mailing address

PO BOX 7410723
CHICAGO IL
60674-0723
US

V. Phone/Fax

Practice location:
  • Phone: 609-585-1122
  • Fax: 215-949-2384
Mailing address:
  • Phone: 609-585-1122
  • Fax: 215-949-2384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010906
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004835
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00096900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: