Provider Demographics
NPI:1245623107
Name:OHUMUKINI, STACEY MARIE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MARIE
Last Name:OHUMUKINI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 2ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1126
Mailing Address - Country:US
Mailing Address - Phone:612-597-2975
Mailing Address - Fax:
Practice Address - Street 1:5480 NATHAN LN N
Practice Address - Street 2:STE 140
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-1997
Practice Address - Country:US
Practice Address - Phone:612-597-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104854225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist