Provider Demographics
NPI:1497148191
Name:STITES, IAN CHRISTOPHER (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:CHRISTOPHER
Last Name:STITES
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:O&C BLDG M7 0355 MAIL CODE IHA 008
Mailing Address - Street 2:
Mailing Address - City:KENNEDY SPACE CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:32899-0001
Mailing Address - Country:US
Mailing Address - Phone:321-867-8004
Mailing Address - Fax:321-867-1144
Practice Address - Street 1:O&C BLDG M7 0355 MAIL CODE IHA 008
Practice Address - Street 2:
Practice Address - City:KENNEDY SPACE CENTER
Practice Address - State:FL
Practice Address - Zip Code:32899-0001
Practice Address - Country:US
Practice Address - Phone:321-867-8004
Practice Address - Fax:321-867-1144
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 29892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer