Healthcare Provider Details

I. General information

NPI: 1790879161
Provider Name (Legal Business Name): STACEY YEARIAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 KINGSLEY AVE
ORANGE PARK FL
32073-4847
US

IV. Provider business mailing address

7704 FAWN LAKE DR S
JACKSONVILLE FL
32256-3692
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-2156
  • Fax:
Mailing address:
  • Phone: 904-288-9577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA20062
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: