Healthcare Provider Details

I. General information

NPI: 1306602602
Provider Name (Legal Business Name): VIRGINIA STANLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 SPENCER WAY
KINGS PARK NY
11754-4032
US

IV. Provider business mailing address

14 SPENCER WAY
KINGS PARK NY
11754-4032
US

V. Phone/Fax

Practice location:
  • Phone: 631-275-8987
  • Fax:
Mailing address:
  • Phone: 631-275-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number262124-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: