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General NPI Number Information
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NPI Number | 1306233655
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Entity Type | Individual
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Provider Name | STACEY ORTIZ LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 04/23/2015
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Last Update Date | 02/01/2026
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Provider Practice Location Address
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Address Line | 6050 SYCAMORE LN N
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City | PLYMOUTH
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State | MN
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Zip | 55442-1402
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Country | US
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Telephone | 651-968-5462
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Fax |
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Provider Business Mailing Address
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Address Line | 524 2ND AVE NE
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City | OSSEO
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State | MN
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Zip | 55369-1111
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Country | US
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Telephone | 763-639-8094
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Fax |
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 3841
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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 | A160417201
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License Number State | WA
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