Healthcare Provider Details

I. General information

NPI: 1275939753
Provider Name (Legal Business Name): TRACI STEWART RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HAMILTON AVE
MONTICELLO NY
12701-1319
US

IV. Provider business mailing address

11 HAMILTON AVE
MONTICELLO NY
12701-1319
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-8080
  • Fax:
Mailing address:
  • Phone: 845-794-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number413399-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: