Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DEWBERRY CT
DIX HILLS NY
11746-5655
US

IV. Provider business mailing address

14A MOCCASIN DR
WHITING NJ
08759-1835
US

V. Phone/Fax

Practice location:
  • Phone: 732-407-8488
  • Fax:
Mailing address:
  • Phone: 732-407-8488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: