1518904614 NPI number — HOLLI STAYTON FNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518904614 NPI number — HOLLI STAYTON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAYTON
Provider First Name:
HOLLI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STANK
Provider Other First Name:
HOLLI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518904614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
346 GRAND AVE
Provider Second Line Business Mailing Address:
UNITED HEALTH SERVICES HOSP INC
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-770-0025
Provider Business Mailing Address Fax Number:
607-729-3982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 OGDEN ST
Provider Second Line Business Practice Location Address:
ROOSEVELT SCHOOL BASED CLINIC
Provider Business Practice Location Address City Name:
BINGHAMTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-762-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2006

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:  333114 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02328765 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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