Healthcare Provider Details

I. General information

NPI: 1669903100
Provider Name (Legal Business Name): ADULT HEALTHCARE NP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 STEWART AVE STE 102
GARDEN CITY NY
11530-4738
US

IV. Provider business mailing address

339 HEMPSTEAD AVE PO BOX 328
MALVERNE NY
11565
US

V. Phone/Fax

Practice location:
  • Phone: 516-515-0597
  • Fax: 516-837-9847
Mailing address:
  • Phone: 516-515-0597
  • Fax: 516-837-9847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number307783
License Number StateNY

VIII. Authorized Official

Name: PROF. CARLETTA STACKHOUSE
Title or Position: CEO
Credential: NP
Phone: 516-515-0597