Healthcare Provider Details

I. General information

NPI: 1255702304
Provider Name (Legal Business Name): STACEY SYKES PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY A WALLACE PT

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8121 KENSINGTON DR STE E
WAXHAW NC
28173-0311
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 704-256-5115
  • Fax:
Mailing address:
  • Phone: 423-238-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305208216
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9834
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP18973
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: