Provider Demographics
NPI:1376026534
Name:ERNST, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:ERNST
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 1:27034 VAUGHNS VW
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-5511
Mailing Address - Country:US
Mailing Address - Phone:210-386-0692
Mailing Address - Fax:
Practice Address - Street 1:1102 RIVER RD
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2436
Practice Address - Country:US
Practice Address - Phone:830-249-2799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2104516225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant