MEDICARE: MRS. STACEY CUNDIFF

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	224Z00000X	Occupational Therapy Assistant	1800218	KS

General Provider Information

NPI Number	:	1689880361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACEY CUNDIFF

Provider Business Mailing Address
First Line	:	804 N 4TH ST
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-5626
Country	:	US
Telephone Number	:	620-290-3125
Fax Number	:	620-275-6582

Provider Business Practice Location Address
First Line	:	804 N 4TH ST
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-5626
Country	:	US
Telephone Number	:	620-290-3125
Fax Number	:	620-275-6582

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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