Healthcare Provider Details

I. General information

NPI: 1801045984
Provider Name (Legal Business Name): THERESA LORRAINE STAVOLA ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HSC T16-080 NICHOLLS RD DEPT OF INTERNAL MEDICINE DIV OF CARDIOLOGY SUNY STONY BROOK UNIVERSITY HOSPITAL
STONY BROOK NY
11794
US

IV. Provider business mailing address

HSC T16-080 NICHOLLS RD DEPT OF INTERNAL MEDICINE DIV OF CARDIOLOGY SUNY STONY BROOK UNIVERSITY HOSPITAL
STONY BROOK NY
11794
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-1066
  • Fax:
Mailing address:
  • Phone: 631-444-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number301910
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: