Healthcare Provider Details

I. General information

NPI: 1699072108
Provider Name (Legal Business Name): STACEY ANN HEFLEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 RISNER ST
LAS CRUCES NM
88011-4822
US

IV. Provider business mailing address

3140 RISNER ST
LAS CRUCES NM
88011-4822
US

V. Phone/Fax

Practice location:
  • Phone: 575-312-7801
  • Fax:
Mailing address:
  • Phone: 575-312-7801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: