Provider Demographics
NPI:1629411749
Name:STICKNEY, NATHAN DALY (DPM)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:DALY
Last Name:STICKNEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 IRA E WOODS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3907
Mailing Address - Country:US
Mailing Address - Phone:817-416-6155
Mailing Address - Fax:817-329-9434
Practice Address - Street 1:2421 IRA E WOODS AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3907
Practice Address - Country:US
Practice Address - Phone:817-416-6155
Practice Address - Fax:817-329-9434
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2061213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery