Healthcare Provider Details

I. General information

NPI: 1497867188
Provider Name (Legal Business Name): STACEY LYNN LOFSTAD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 LOCUST PL
COPIAGUE NY
11726-3509
US

IV. Provider business mailing address

14 LOCUST PL
COPIAGUE NY
11726-3509
US

V. Phone/Fax

Practice location:
  • Phone: 631-608-1622
  • Fax:
Mailing address:
  • Phone: 631-608-1622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000077-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: