Basic Information
| Provider Information | |||||||||
| NPI: | 1215495700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLABOUGH | ||||||||
| FirstName: | STACI | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1618 DOLPHIN LN | ||||||||
| Address2: | |||||||||
| City: | HOLBROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117416215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303466716 | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 BELLE TERRE RD STE 209 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740707 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2019 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 344145 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.