Provider Demographics
NPI:1629472162
Name:NIEVEEN, STACIE N (PT)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:N
Last Name:NIEVEEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:N
Other - Last Name:GORACKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5790 N 33RD ST
Mailing Address - Street 2:STE A
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68504-4651
Mailing Address - Country:US
Mailing Address - Phone:402-436-2535
Mailing Address - Fax:402-436-2996
Practice Address - Street 1:6900 A ST
Practice Address - Street 2:STE 102
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4120
Practice Address - Country:US
Practice Address - Phone:402-436-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3356225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist