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General NPI Number Information
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NPI Number | 1144634601
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Entity Type | Individual
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Provider Name | STACEY JOHN ATC, OTC
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Gender | Female
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Dates
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Enumeration Date | 06/12/2014
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Last Update Date | 01/29/2020
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Provider Practice Location Address
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Address Line | 3580 ARCADE ST
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City | VADNAIS HEIGHTS
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State | MN
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Zip | 55127-7135
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Country | US
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Telephone | 651-968-5375
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Fax | 651-968-5907
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Provider Business Mailing Address
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Address Line | 1285 NININGER RD
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City | HASTINGS
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State | MN
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Zip | 55033-1086
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Country | US
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Telephone | 651-968-5413
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Fax | 651-437-2988
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 18-2775
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2280
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License Number State | MN
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