Provider Demographics
NPI:1154776102
Name:BERTRAM, STACY M (LPN)
Entity type:Individual
Prefix:MISS
First Name:STACY
Middle Name:M
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:M
Other - Last Name:LYNCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 GRAMATAN AVE
Mailing Address - Street 2:APT G85
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-3245
Mailing Address - Country:US
Mailing Address - Phone:914-437-1455
Mailing Address - Fax:
Practice Address - Street 1:300 GRAMATAN AVE
Practice Address - Street 2:APT G85
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-3245
Practice Address - Country:US
Practice Address - Phone:914-437-1455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274466164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse