Provider Demographics
NPI:1780931972
Name:STORK, ALEXANDRA LUCILLE (PT)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:LUCILLE
Last Name:STORK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 PLEASANT STREET
Mailing Address - Street 2:SOUTH 2 ROOM 236
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309
Mailing Address - Country:US
Mailing Address - Phone:515-241-6228
Mailing Address - Fax:515-241-8685
Practice Address - Street 1:50 E HICKMAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263
Practice Address - Country:US
Practice Address - Phone:515-216-2999
Practice Address - Fax:515-471-9243
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA004955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist