Provider Demographics
NPI:1467968602
Name:HUMMEL, STACEY KIM (PTA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:KIM
Last Name:HUMMEL
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 1:324 BURKET LN
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-1977
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:316 WOODIES LN
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1354
Practice Address - Country:US
Practice Address - Phone:574-546-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003185A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant