Provider Demographics
NPI:1194276584
Name:WILSON, STACY MARIE (LPN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:WILSON
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 1:511 NORTH GREEN RD
Mailing Address - Street 2:
Mailing Address - City:FULTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12072
Mailing Address - Country:US
Mailing Address - Phone:518-775-0958
Mailing Address - Fax:
Practice Address - Street 1:127 EAST STATE STREET
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1204
Practice Address - Country:US
Practice Address - Phone:518-775-5354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316128-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse