Provider Demographics
NPI:1508106667
Name:STREET, STACIE NICOLE
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:NICOLE
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:NICOLE
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31199 WILSON MYRTLE DR
Mailing Address - Street 2:
Mailing Address - City:MILLSBORO
Mailing Address - State:DE
Mailing Address - Zip Code:19966-4638
Mailing Address - Country:US
Mailing Address - Phone:302-381-9354
Mailing Address - Fax:
Practice Address - Street 1:101 E STATE ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3109
Practice Address - Country:US
Practice Address - Phone:610-444-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000766225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant