Basic Information
| Provider Information | |||||||||
| NPI: | 1801045984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAVOLA | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | LORRAINE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | HSC T16-080 NICHOLLS RD DEPT OF INTERNAL MEDICINE | ||||||||
| Address2: | DIV OF CARDIOLOGY SUNY STONY BROOK UNIVERSITY HOSPITAL | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314441066 | ||||||||
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| Practice Location | |||||||||
| Address1: | HSC T16-080 NICHOLLS RD DEPT OF INTERNAL MEDICINE | ||||||||
| Address2: | DIV OF CARDIOLOGY SUNY STONY BROOK UNIVERSITY HOSPITAL | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314441066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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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 | 363LA2200X | 301910 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.