MEDICARE: STACEY ANN HEFLEY PTA

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	225200000X	Physical Therapy Assistant	A-0711	NM

General Provider Information

NPI Number	:	1699072108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY ANN HEFLEY PTA

Provider Business Mailing Address
First Line	:	3140 RISNER ST
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4822
Country	:	US
Telephone Number	:	575-312-7801
Fax Number	:

Provider Business Practice Location Address
First Line	:	3140 RISNER ST
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-4822
Country	:	US
Telephone Number	:	575-312-7801
Fax Number	:

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

Provider Enumeration Date	:	02/17/2011
Last Update Date	:	02/17/2011

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