Provider Demographics
NPI:1174961858
Name:HEYWARD, STACEY DINEEN
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:DINEEN
Last Name:HEYWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 JACKSON AVE
Mailing Address - Street 2:3E
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-7739
Mailing Address - Country:US
Mailing Address - Phone:646-456-9996
Mailing Address - Fax:
Practice Address - Street 1:820 JACKSON AVE
Practice Address - Street 2:3E
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-7739
Practice Address - Country:US
Practice Address - Phone:646-456-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY503820174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist