Basic Information
| Provider Information | |||||||||
| NPI: | 1588904320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON-STACEY | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2231 BURDETT AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121802453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183261620 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2013 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | FOO1506-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 176B00000X | 001506 | NY | Y | Other Service Providers | Midwife |
No ID Information.