Provider Demographics
NPI:1689100992
Name:WILSON, STACEY LYNN
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:WILSON
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 1:3022 YORKTOWN CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-3212
Mailing Address - Country:US
Mailing Address - Phone:812-899-2700
Mailing Address - Fax:
Practice Address - Street 1:3022 YORKTOWN CT
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-3212
Practice Address - Country:US
Practice Address - Phone:812-899-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003530A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant