Provider Demographics
NPI:1639440183
Name:CONDER, STACY NICOLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICOLE
Last Name:CONDER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 N CASWELL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2470
Mailing Address - Country:US
Mailing Address - Phone:704-379-7773
Mailing Address - Fax:704-423-5775
Practice Address - Street 1:341 N CASWELL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2470
Practice Address - Country:US
Practice Address - Phone:704-379-7773
Practice Address - Fax:704-423-5775
Is Sole Proprietor?:No
Enumeration Date:2012-01-14
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist