Provider Demographics
NPI:1427563071
Name:ABBOTT, STACEY LYNN (NP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:FOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-368-4006
Practice Address - Fax:585-368-4009
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382806363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05028973Medicaid