Provider Demographics
NPI:1578049490
Name:TAGUE, STEPHANIE JO
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JO
Last Name:TAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 28TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-1955
Mailing Address - Country:US
Mailing Address - Phone:563-243-6600
Mailing Address - Fax:
Practice Address - Street 1:801 28TH AVE N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-1955
Practice Address - Country:US
Practice Address - Phone:563-243-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 376J00000X
IA001311225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker