Provider Demographics
NPI:1881656346
Name:FEDORKA, STACIE BLIER (MPT)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:BLIER
Last Name:FEDORKA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:MARIE
Other - Last Name:BLIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 CRESCENT CENTRE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7285
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:2001 MALLORY LN
Practice Address - Street 2:SUITE 204
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-8233
Practice Address - Country:US
Practice Address - Phone:615-550-0005
Practice Address - Fax:615-550-0006
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2458225100000X
TN10004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist