Provider Demographics
NPI:1720393648
Name:MAIGNAN, STACEY ANN (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:MAIGNAN
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 1:514 MISTY WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:ROLESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27571-9365
Mailing Address - Country:US
Mailing Address - Phone:513-404-1897
Mailing Address - Fax:
Practice Address - Street 1:514 MISTY WILLOW WAY
Practice Address - Street 2:
Practice Address - City:ROLESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27571-9365
Practice Address - Country:US
Practice Address - Phone:513-404-1897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP124172251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics