Provider Demographics
NPI:1679926125
Name:HOLMES, STACY LORRAINE
Entity type:Individual
Prefix:MISS
First Name:STACY
Middle Name:LORRAINE
Last Name:HOLMES
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 1:157 ROXBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1417
Mailing Address - Country:US
Mailing Address - Phone:585-775-1588
Mailing Address - Fax:
Practice Address - Street 1:157 ROXBOROUGH RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1417
Practice Address - Country:US
Practice Address - Phone:585-775-1588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325961164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04579791Medicaid