Provider Demographics
NPI:1679154991
Name:STUCKER, LESLEY R (PT)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:R
Last Name:STUCKER
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 1:18317 160TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:IA
Mailing Address - Zip Code:50220-6314
Mailing Address - Country:US
Mailing Address - Phone:515-360-0082
Mailing Address - Fax:
Practice Address - Street 1:2400 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE CENTER
Practice Address - State:IA
Practice Address - Zip Code:50115-8878
Practice Address - Country:US
Practice Address - Phone:641-747-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherWELLMARK BLUE CROSS BLUE SHIELD