Provider Demographics
NPI:1093289100
Name:DILLARD, STACEY LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:DILLARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 DENISE DR
Mailing Address - Street 2:
Mailing Address - City:OLD HICKORY
Mailing Address - State:TN
Mailing Address - Zip Code:37138-1513
Mailing Address - Country:US
Mailing Address - Phone:615-879-9780
Mailing Address - Fax:
Practice Address - Street 1:4347 LEBANON PIKE
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-1243
Practice Address - Country:US
Practice Address - Phone:615-871-8283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3961225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant