Healthcare Provider Details

I. General information

NPI: 1790113983
Provider Name (Legal Business Name): STACI HEFFNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 W FAIR AVE
LANCASTER OH
43130-2318
US

IV. Provider business mailing address

1405 W FAIR AVE
LANCASTER OH
43130-2318
US

V. Phone/Fax

Practice location:
  • Phone: 740-304-2315
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.09223
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: