Provider Demographics
NPI:1134698871
Name:BEQUETTE, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BEQUETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 SPOTTED OWL DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-4402
Mailing Address - Country:US
Mailing Address - Phone:573-465-6038
Mailing Address - Fax:
Practice Address - Street 1:1817 SPOTTED OWL DR
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-4402
Practice Address - Country:US
Practice Address - Phone:573-465-6038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant