Provider Demographics
NPI:1174745293
Name:MEMMESHEIMER, STACI MARIE (FNP)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:MARIE
Last Name:MEMMESHEIMER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 GRAHAM BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4056
Mailing Address - Country:US
Mailing Address - Phone:718-979-0695
Mailing Address - Fax:
Practice Address - Street 1:25 HYATT ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-1827
Practice Address - Country:US
Practice Address - Phone:718-808-1317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333983363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily