Provider Demographics
NPI:1861154874
Name:PETERSEN, STACEY LYNN
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 N BROADWAY
Mailing Address - Street 2:2S
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-7036
Mailing Address - Country:US
Mailing Address - Phone:646-335-8979
Mailing Address - Fax:
Practice Address - Street 1:56 N BROADWAY
Practice Address - Street 2:2S
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-7036
Practice Address - Country:US
Practice Address - Phone:646-335-8979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY000429189E251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care