=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619657137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY MOUSAW CARPENTER PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2023
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 PROSPECT AVE
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13203-1899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-726-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5465 ORANGEPORT RD UNIT 503
-----------------------------------------------------
City | BREWERTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13029-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-675-8887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 404991
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------