Provider Demographics
NPI:1528365269
Name:LATA, STACY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:LATA
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 1:17323 CAMPILLO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2149
Mailing Address - Country:US
Mailing Address - Phone:185-848-5084
Mailing Address - Fax:
Practice Address - Street 1:17323 CAMPILLO DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2149
Practice Address - Country:US
Practice Address - Phone:858-485-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 1715225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant