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NPI Code Detail

MEDICARE: STACEY LEE FLEETWOOD MSPT

MEDICARE: STACEY LEE FLEETWOOD MSPT
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
1225100000XPhysical Therapist11-02852KS
2225100000XPhysical Therapist2004009998MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12004009998OTHERMOSTATE LICENSE
211-02852OTHERKSSTATE LICENSE

General Provider Information

NPI Number : 1538294772
Entity Type Code : Individual
Provider Name (Legal Business Name) : STACEY LEE FLEETWOOD MSPT
Provider Business Mailing Address
First Line : 4911 STATE AVE
Second Line :
City : KANSAS CITY
State : KS
Zip : 66102-1749
Country : US
Telephone Number : 913-287-8851
Fax Number :
Provider Business Practice Location Address
First Line : 4911 STATE AVE
Second Line :
City : KANSAS CITY
State : KS
Zip : 66102-1749
Country : US
Telephone Number : 913-287-8851
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/21/2007
Last Update Date : 03/15/2011

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