Healthcare Provider Details

I. General information

NPI: 1255153268
Provider Name (Legal Business Name): STACEY SOOMIN YOUN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 10/30/2024
Certification Date: 10/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

436 9TH STREET SUITE B
PALISADES PARK NJ
07650
US

V. Phone/Fax

Practice location:
  • Phone: 646-929-7800
  • Fax:
Mailing address:
  • Phone: 860-338-6677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number433161
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: