Provider Demographics
NPI:1861801623
Name:LAROSA, STACEY (APRN)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LAROSA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST, CB-2041
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-824-1245
Mailing Address - Fax:203-200-2657
Practice Address - Street 1:20 YORK ST, CB-2041
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-824-1245
Practice Address - Fax:203-200-2657
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2017-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner