Provider Demographics
NPI:1316346638
Name:CREIGHTON, STACEY
Entity type:Individual
Prefix:PROF
First Name:STACEY
Middle Name:
Last Name:CREIGHTON
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 1:13295 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14004-1324
Mailing Address - Country:US
Mailing Address - Phone:716-902-5025
Mailing Address - Fax:716-937-4136
Practice Address - Street 1:13295 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALDEN
Practice Address - State:NY
Practice Address - Zip Code:14004-1324
Practice Address - Country:US
Practice Address - Phone:716-902-5025
Practice Address - Fax:716-937-4136
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies