Provider Demographics
NPI:1730600560
Name:STACY, LAURA JEAN (LPN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:STACY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1064
Mailing Address - Country:US
Mailing Address - Phone:315-598-3627
Mailing Address - Fax:
Practice Address - Street 1:104 W 4TH ST N
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1064
Practice Address - Country:US
Practice Address - Phone:315-598-3627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-01
Last Update Date:2017-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244449-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse