Healthcare Provider Details

I. General information

NPI: 1194166538
Provider Name (Legal Business Name): PAULA M STOMMES OTR L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAULA M STOMMES

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date: 03/19/2013
Reactivation Date: 07/15/2013

III. Provider practice location address

9401 WINNETKA AVE N
BROOKLYN PARK MN
55445-1618
US

IV. Provider business mailing address

9401 WINNETKA AVE. N RELIABLE MEDICAL SUPPLY
BROOKLYN PARK MN
55445
US

V. Phone/Fax

Practice location:
  • Phone: 763-255-3810
  • Fax: 763-255-3910
Mailing address:
  • Phone: 763-255-3810
  • Fax: 763-255-3910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number102195
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: