Healthcare Provider Details

I. General information

NPI: 1487904249
Provider Name (Legal Business Name): STACEY L SPAHN REGISTER NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 MAIDEN LN
ROCHESTER NY
14615-1230
US

IV. Provider business mailing address

750 MAIDEN LN
ROCHESTER NY
14615-1230
US

V. Phone/Fax

Practice location:
  • Phone: 585-966-5205
  • Fax:
Mailing address:
  • Phone: 585-966-5205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number572334
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: