Healthcare Provider Details

I. General information

NPI: 1215276555
Provider Name (Legal Business Name): STACEY MARIE DAVIS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2013
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 W IRONWOOD CENTER DR B
COEUR D ALENE ID
83814-2606
US

IV. Provider business mailing address

2170 W IRONWOOD CENTER DR
COEUR D ALENE ID
83814-2606
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-1988
  • Fax: 208-765-5654
Mailing address:
  • Phone: 208-667-1988
  • Fax: 208-765-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60322487
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: