Healthcare Provider Details

I. General information

NPI: 1639347065
Provider Name (Legal Business Name): DARLEEN KAY STOUDEMIRE OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 COURT ST
SYRACUSE NY
13208-3217
US

IV. Provider business mailing address

38 TOWN LINE RD
FULTON NY
13069-4549
US

V. Phone/Fax

Practice location:
  • Phone: 315-455-8933
  • Fax:
Mailing address:
  • Phone: 315-592-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number005835-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: