MEDICARE: MS. STACY ELLEN HORNE MS, PT

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	225100000X	Physical Therapist	PT015608	PA

General Provider Information

NPI Number	:	1972819837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACY ELLEN HORNE MS, PT

Provider Business Mailing Address
First Line	:	PO BOX 526
Second Line	:	66 LAKE NATALIE DRIVE
City	:	GOULDSBORO
State	:	PA
Zip	:	18424-0526
Country	:	US
Telephone Number	:	570-309-8070
Fax Number	:	570-842-0551

Provider Business Practice Location Address
First Line	:	66 LAKE NATALIE DR
Second Line	:
City	:	GOULDSBORO
State	:	PA
Zip	:	18424-8846
Country	:	US
Telephone Number	:	570-309-8070
Fax Number	:	570-842-0551

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

Provider Enumeration Date	:	08/29/2010
Last Update Date	:	08/29/2010

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