Provider Demographics
NPI:1609623479
Name:VALENTINE, STACYAN P
Entity type:Individual
Prefix:
First Name:STACYAN
Middle Name:P
Last Name:VALENTINE
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 1:165 PASSAIC AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-3521
Mailing Address - Country:US
Mailing Address - Phone:862-276-5137
Mailing Address - Fax:
Practice Address - Street 1:165 PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-3521
Practice Address - Country:US
Practice Address - Phone:862-276-5137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0451091871342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company