Provider Demographics
NPI:1588136303
Name:OSBOURNE, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:OSBOURNE
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 1:24311 147TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2417
Mailing Address - Country:US
Mailing Address - Phone:917-459-1511
Mailing Address - Fax:
Practice Address - Street 1:24311 147TH AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2417
Practice Address - Country:US
Practice Address - Phone:718-470-2940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QA0600X, 261QA3000X, 261QM0801X
261QD1600X, 261QA0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QA3000XAmbulatory Health Care FacilitiesClinic/CenterAugmentative Communication
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)