Provider Demographics
NPI:1578209524
Name:REYES DAVID, STACY K
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:K
Last Name:REYES DAVID
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 1:3295 TRANQUILITY CT UNIT 1
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-6380
Mailing Address - Country:US
Mailing Address - Phone:407-990-9095
Mailing Address - Fax:
Practice Address - Street 1:3455 REWAK DR STE 106
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5024
Practice Address - Country:US
Practice Address - Phone:907-457-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK177500225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant