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General NPI Number Information
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NPI Number | 1932257110
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Entity Type | Individual
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Provider Name | STACIE NICHOLE WOODWORTH ATC
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Gender | Female
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Dates
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Enumeration Date | 01/06/2007
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Last Update Date | 12/29/2015
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Provider Practice Location Address
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Address Line | 2128 MIDLANDS CT
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City | SYCAMORE
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State | IL
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Zip | 60178-3199
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Country | US
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Telephone | 815-758-0000
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Fax |
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Provider Business Mailing Address
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Address Line | 315 W CHESTER DR
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City | MAPLE PARK
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State | IL
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Zip | 60151-9193
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Country | US
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Telephone | 630-707-7556
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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 | 96001400
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License Number State | IL
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