Provider Demographics
NPI:1174867295
Name:EDWARDS, STACEY (PTA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:EDWARDS
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 1:3737 LANDINGS DR
Mailing Address - Street 2:A4
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3159
Mailing Address - Country:US
Mailing Address - Phone:720-299-4458
Mailing Address - Fax:
Practice Address - Street 1:3737 LANDINGS DR
Practice Address - Street 2:A4
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3159
Practice Address - Country:US
Practice Address - Phone:720-299-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12391225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12391OtherMEDICARE