Provider Demographics
NPI:1861091324
Name:JANTSCH, STACEY M (AGNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:JANTSCH
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 MADISON AVE STE 2817
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5101
Mailing Address - Country:US
Mailing Address - Phone:888-553-2823
Mailing Address - Fax:888-553-2823
Practice Address - Street 1:169 MADISON AVE STE 2817
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5101
Practice Address - Country:US
Practice Address - Phone:888-553-2823
Practice Address - Fax:888-553-2823
Is Sole Proprietor?:No
Enumeration Date:2020-10-25
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704415079363L00000X
NYF310040-01363LA2200X
NY310040363LG0600X, 363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0055828Medicaid
NY06431149Medicaid
CTD401115801Medicaid
MI1861091324Medicaid