Provider Demographics
NPI:1588904320
Name:GORDON-STACEY, CARRIE JEAN (CNM)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:JEAN
Last Name:GORDON-STACEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:2231 BURDETT AVE STE 160
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2453
Practice Address - Country:US
Practice Address - Phone:518-326-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYFOO1506-1367A00000X
NY001506176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife