Provider Demographics
NPI:1235507690
Name:STIFTER, ASHLEY (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:STIFTER
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 NORTHGATE DR
Mailing Address - Street 2:PO BOX 410
Mailing Address - City:WINSTED
Mailing Address - State:MN
Mailing Address - Zip Code:55395-1056
Mailing Address - Country:US
Mailing Address - Phone:952-564-7506
Mailing Address - Fax:
Practice Address - Street 1:2700 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2990
Practice Address - Country:US
Practice Address - Phone:612-345-7769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MN11695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1235507690Medicaid