Healthcare Provider Details

I. General information

NPI: 1538469770
Provider Name (Legal Business Name): ANGELA DOUGLAS-STALEY RN, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2369 2ND AVE
NEW YORK NY
10035-3108
US

IV. Provider business mailing address

413 BEACH AVE
BRONX NY
10473-3609
US

V. Phone/Fax

Practice location:
  • Phone: 212-876-2300
  • Fax:
Mailing address:
  • Phone: 646-528-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401312-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: