MEDICARE: STACIE NICOLE MALLOY DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2010024372	MO

General Provider Information

NPI Number	:	1134566144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE NICOLE MALLOY DPT

Provider Business Mailing Address
First Line	:	27110 JOINER DR
Second Line	:
City	:	ST CATHARINE
State	:	MO
Zip	:	64628-8217
Country	:	US
Telephone Number	:	660-258-8645
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 N MAIN ST
Second Line	:
City	:	BROOKFIELD
State	:	MO
Zip	:	64628-1643
Country	:	US
Telephone Number	:	660-258-7892
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2013
Last Update Date	:	05/20/2014

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