Provider Demographics
NPI:1366205056
Name:TERRY, STACEY LEIGH
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LEIGH
Last Name:TERRY
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 1:397 STATE HIGHWAY 357
Mailing Address - Street 2:
Mailing Address - City:UNADILLA
Mailing Address - State:NY
Mailing Address - Zip Code:13849-3311
Mailing Address - Country:US
Mailing Address - Phone:607-434-7851
Mailing Address - Fax:
Practice Address - Street 1:19 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1418
Practice Address - Country:US
Practice Address - Phone:315-853-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist