Healthcare Provider Details

I. General information

NPI: 1962641670
Provider Name (Legal Business Name): STACY HORSFALL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17280 W NORTH AVE #104
BROOKFIELD WI
53045-4366
US

IV. Provider business mailing address

17280 W NORTH AVE #104
BROOKFIELD WI
53045-4366
US

V. Phone/Fax

Practice location:
  • Phone: 262-780-0707
  • Fax:
Mailing address:
  • Phone: 262-780-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1559
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: