Healthcare Provider Details

I. General information

NPI: 1942463120
Provider Name (Legal Business Name): MRS. STACEY A COOL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 ST HIGHWAY 331
ST JOHNSVILLE NY
13452-2818
US

IV. Provider business mailing address

136 ST HIGHWAY 331
ST JOHNSVILLE NY
13452-2818
US

V. Phone/Fax

Practice location:
  • Phone: 518-568-5960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number10282261
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: