Provider Demographics
NPI:1578375028
Name:PERRETTA, STACIE L (LPN)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:L
Last Name:PERRETTA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 582
Mailing Address - Street 2:
Mailing Address - City:BRIER HILL
Mailing Address - State:NY
Mailing Address - Zip Code:13614-0582
Mailing Address - Country:US
Mailing Address - Phone:315-323-6738
Mailing Address - Fax:
Practice Address - Street 1:1 CHIMNEY POINT DR
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2291
Practice Address - Country:US
Practice Address - Phone:315-541-2526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271186164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse