Healthcare Provider Details

I. General information

NPI: 1679288062
Provider Name (Legal Business Name): STACEY LYKE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 HALE LAKE POINTE
GRAND RAPIDS MN
55744-9615
US

IV. Provider business mailing address

5786 MARTIMA RD
FLOODWOOD MN
55736-8124
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-0543
  • Fax:
Mailing address:
  • Phone: 218-461-6403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2580
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: