Provider Demographics
NPI:1568043081
Name:DRAKE, STACIE C (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:C
Last Name:DRAKE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E 60TH ST RM 704
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1799
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 E 60TH ST RM 704
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1799
Practice Address - Country:US
Practice Address - Phone:631-323-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29481363LP0808X
NYF405817-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health