=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245386317
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY A PENDELL PNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 11/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 - 42 MITCHELL AVENUE
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-762-2468
-----------------------------------------------------
Fax | 607-762-3871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 346 GRAND AVE
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13790-2580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-762-2468
-----------------------------------------------------
Fax | 607-762-3871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | F381553
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------