Provider Demographics
NPI:1366760373
Name:BLACKMAN, STACEY MELISSA (APN)
Entity type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:MELISSA
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1907
Mailing Address - Country:US
Mailing Address - Phone:201-341-8190
Mailing Address - Fax:
Practice Address - Street 1:9 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018
Practice Address - Country:US
Practice Address - Phone:201-341-8190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00286100173000000X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No173000000XOther Service ProvidersLegal Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily