Healthcare Provider Details

I. General information

NPI: 1114202504
Provider Name (Legal Business Name): STACEY A BURT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. STACEY A RIDDLEBERGER

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1376 RIVER RD
BINGHAMTON NY
13901-5702
US

IV. Provider business mailing address

1376 RIVER RD
BINGHAMTON NY
13901-5702
US

V. Phone/Fax

Practice location:
  • Phone: 607-821-8739
  • Fax:
Mailing address:
  • Phone: 607-821-8739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number402391-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number402391-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: