Provider Demographics
NPI:1457334674
Name:HORNER, STACY JLYN (PT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JLYN
Last Name:HORNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:JLYN
Other - Last Name:DEHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2500 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9718
Mailing Address - Country:US
Mailing Address - Phone:970-493-0112
Mailing Address - Fax:
Practice Address - Street 1:2500 E PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9718
Practice Address - Country:US
Practice Address - Phone:970-493-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0004987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00374924OtherRR MEDICARE
WY12017600Medicaid
CO75255545Medicaid
CO75255545Medicaid