MEDICARE: STACIE DEE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F401771-1	NY

General Provider Information

NPI Number	:	1295132058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STACIE DEE LLC

Provider Business Mailing Address
First Line	:	525 E 72ND ST
Second Line	:	APARTMENT 35B
City	:	NEW YORK
State	:	NY
Zip	:	10021-9601
Country	:	US
Telephone Number	:	860-604-8585
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 E 72ND ST
Second Line	:	APARTMENT 35B
City	:	NEW YORK
State	:	NY
Zip	:	10021-9601
Country	:	US
Telephone Number	:	860-604-8585
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. STACIE A DEE
Credential	:	MSN
Telephone Number	:	860-604-8585

Provider Enumeration Date	:	11/21/2014
Last Update Date	:	11/21/2014

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