Provider Demographics
NPI:1467739367
Name:THEISEN, STACI M (ATC)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:M
Last Name:THEISEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 ELENA LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MN
Mailing Address - Zip Code:56374-4596
Mailing Address - Country:US
Mailing Address - Phone:612-219-4492
Mailing Address - Fax:
Practice Address - Street 1:158 19TH ST S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2153
Practice Address - Country:US
Practice Address - Phone:320-253-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer