Provider Demographics
NPI:1538420427
Name:MANZI, STACEY (MSED)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:MANZI
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 N HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-1624
Mailing Address - Country:US
Mailing Address - Phone:631-566-2950
Mailing Address - Fax:
Practice Address - Street 1:18 N HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-1624
Practice Address - Country:US
Practice Address - Phone:631-566-2950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1312777174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist