Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 9957 | NY |
NPI | 1093222036 |
---|---|
Provider Name | Stacie Overton |
First Address | Riverhead, NY 11901-4453 |
Second Address | Riverhead, NY 11901-4453 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2017 |
Last Update Date | 29/12/2017 |