Healthcare Provider Details

I. General information

NPI: 1215309927
Provider Name (Legal Business Name): STACEY MARR PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 S LEMON AVE # 6219
WALNUT CA
91789-2706
US

IV. Provider business mailing address

340 S LEMON AVE # 6219
WALNUT CA
91789-2706
US

V. Phone/Fax

Practice location:
  • Phone: 541-921-1121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 25595
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number08039
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: