Provider Demographics
NPI:1699203901
Name:GIBSON, STACEE MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:STACEE
Middle Name:MARIE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MS
Other - First Name:STACEE
Other - Middle Name:MAIRE
Other - Last Name:ROUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:4146 WINNEPEG CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5705
Mailing Address - Country:US
Mailing Address - Phone:859-274-2128
Mailing Address - Fax:
Practice Address - Street 1:400 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1628
Practice Address - Country:US
Practice Address - Phone:859-274-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTCA5182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer