MEDICARE: STACY SANICOLA NURSE PRACTITIONER

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	363LF0000X	Family Nurse Practitioner	342171	NY

General Provider Information

NPI Number	:	1790200459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY SANICOLA NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	73 GERVIL ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-4230
Country	:	US
Telephone Number	:	917-295-3957
Fax Number	:

Provider Business Practice Location Address
First Line	:	477 PHILIP AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-5818
Country	:	US
Telephone Number	:	917-295-3957
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2017
Last Update Date	:	04/11/2023

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