Healthcare Provider Details

I. General information

NPI: 1700923588
Provider Name (Legal Business Name): STACEY RAE CLENDENNING PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 DIPLOMACY DR
ANCHORAGE AK
99508-5926
US

IV. Provider business mailing address

4321 AMBLER CIR
ANCHORAGE AK
99504-4698
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-1249
  • Fax:
Mailing address:
  • Phone: 907-337-4323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1803
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: