Provider Demographics
NPI:1780017921
Name:CHUDOMELKA, STACEY JO (PTA)
Entity Type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:JO
Last Name:CHUDOMELKA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:NE
Mailing Address - Zip Code:69154-0373
Mailing Address - Country:US
Mailing Address - Phone:402-598-4259
Mailing Address - Fax:
Practice Address - Street 1:1100 W 2ND ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:NE
Practice Address - Zip Code:69154-6152
Practice Address - Country:US
Practice Address - Phone:308-772-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1209225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant