Provider Demographics
NPI:1518116508
Name:ANTONUCCI, STACEY LYNN (CRNP)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:ANTONUCCI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:KWASNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:91 HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:DAISYTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15427-1089
Mailing Address - Country:US
Mailing Address - Phone:724-632-5432
Mailing Address - Fax:
Practice Address - Street 1:90 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4524
Practice Address - Country:US
Practice Address - Phone:724-228-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily