Provider Demographics
NPI:1881688588
Name:RIDDLING, STACI W (PT)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:W
Last Name:RIDDLING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:JOICE
Other - Last Name:WOODARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 8847
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32006-0019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:534 S 5TH ST # A
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063
Practice Address - Country:US
Practice Address - Phone:904-259-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889518000Medicaid