Healthcare Provider Details

I. General information

NPI: 1548220999
Provider Name (Legal Business Name): STACI LYNN PORTER MSPT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 E UNIVERSITY AVE
DES MOINES IA
50317-8236
US

IV. Provider business mailing address

205 W WACKER DR SUITE 1020
CHICAGO IL
60606-1216
US

V. Phone/Fax

Practice location:
  • Phone: 515-265-8272
  • Fax: 515-265-0176
Mailing address:
  • Phone: 312-640-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number03279
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: