Healthcare Provider Details

I. General information

NPI: 1518116508
Provider Name (Legal Business Name): STACEY LYNN ANTONUCCI CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY LYNN KWASNY RN

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 W CHESTNUT ST
WASHINGTON PA
15301-4524
US

IV. Provider business mailing address

91 HICKORY RD
DAISYTOWN PA
15427-1089
US

V. Phone/Fax

Practice location:
  • Phone: 724-228-7113
  • Fax:
Mailing address:
  • Phone: 724-632-5432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP009961
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: