Provider Demographics
NPI:1770855421
Name:EMMANUEL, STACY-ANN MELISSA
Entity Type:Individual
Prefix:
First Name:STACY-ANN
Middle Name:MELISSA
Last Name:EMMANUEL
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 1:4850 W OAKLAND PARK BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-7268
Mailing Address - Country:US
Mailing Address - Phone:954-735-1035
Mailing Address - Fax:
Practice Address - Street 1:4850 W OAKLAND PARK BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7268
Practice Address - Country:US
Practice Address - Phone:954-735-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22335225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant