1518116508 NPI number — MRS. STACEY LYNN ANTONUCCI CRNP

Table of content: MRS. STACEY LYNN ANTONUCCI CRNP (NPI 1518116508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518116508 NPI number — MRS. STACEY LYNN ANTONUCCI CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTONUCCI
Provider First Name:
STACEY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KWASNY
Provider Other First Name:
STACEY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518116508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
91 HICKORY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAISYTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15427-1089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-632-5432
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 W CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15301-4524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-228-7113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  SP009961 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)