Healthcare Provider Details

I. General information

NPI: 1225512163
Provider Name (Legal Business Name): STACIE WALSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4252 158TH ST # 2
FLUSHING NY
11358-2509
US

IV. Provider business mailing address

4252 158TH ST # 2
FLUSHING NY
11358-2509
US

V. Phone/Fax

Practice location:
  • Phone: 631-926-0127
  • Fax:
Mailing address:
  • Phone: 631-926-0127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number724592
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: