Provider Demographics
NPI:1003945387
Name:HESS, STACEY COLEMAN (PTA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:COLEMAN
Last Name:HESS
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 1:1135 BROOK MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-2964
Mailing Address - Country:US
Mailing Address - Phone:704-837-9565
Mailing Address - Fax:
Practice Address - Street 1:1215 E ORANGE ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5762
Practice Address - Country:US
Practice Address - Phone:863-802-3800
Practice Address - Fax:863-802-0480
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20620225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA20620OtherFL PROFESSIONAL LICENSE