Healthcare Provider Details

I. General information

NPI: 1518130202
Provider Name (Legal Business Name): STEPHANIE LEIGH HULL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 S CHICAGO ST
GENESEO IL
61254-1711
US

IV. Provider business mailing address

613 S CHICAGO ST
GENESEO IL
61254-1711
US

V. Phone/Fax

Practice location:
  • Phone: 309-944-9408
  • Fax:
Mailing address:
  • Phone: 309-944-9408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: