MEDICARE: VICKI STAFKO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL 4289	FL
2	2255A2300X	Athletic Trainer	AT0914	TX

General Provider Information

NPI Number	:	1184092249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKI STAFKO

Provider Business Mailing Address
First Line	:	3296 RELAY RD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-7911
Country	:	US
Telephone Number	:	512-297-9146
Fax Number	:

Provider Business Practice Location Address
First Line	:	3296 RELAY RD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-7911
Country	:	US
Telephone Number	:	512-297-9146
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2015
Last Update Date	:	09/07/2015

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Directions to “ VICKI STAFKO ” Practice Location

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