Provider Demographics
NPI:1427299197
Name:WALL, STACEY B (NP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:B
Last Name:WALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:945 E GENESEE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1752
Mailing Address - Country:US
Mailing Address - Phone:315-475-8401
Mailing Address - Fax:315-475-0824
Practice Address - Street 1:945 E GENESEE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1752
Practice Address - Country:US
Practice Address - Phone:315-475-8401
Practice Address - Fax:315-475-0824
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2012-01-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYF300896363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health