Provider Demographics
NPI:1760028252
Name:CLEMENTS, STEFANI KATHERINE (LMT, CFT)
Entity Type:Individual
Prefix:
First Name:STEFANI
Middle Name:KATHERINE
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:LMT, CFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3190 E MERIDIAN PARK LOOP STE 207
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7422
Mailing Address - Country:US
Mailing Address - Phone:907-357-9590
Mailing Address - Fax:907-373-9461
Practice Address - Street 1:3190 E MERIDIAN PARK LOOP STE 207
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7422
Practice Address - Country:US
Practice Address - Phone:907-357-9590
Practice Address - Fax:907-373-9461
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK151531225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist