Provider Demographics
NPI:1801063060
Name:WHITE, STACY ANN (ATC)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NUTSWAMP RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-3807
Mailing Address - Country:US
Mailing Address - Phone:732-706-6111
Mailing Address - Fax:732-706-8058
Practice Address - Street 1:900 NUTSWAMP RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-3807
Practice Address - Country:US
Practice Address - Phone:732-706-6111
Practice Address - Fax:732-706-8058
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000466002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28MT00046600OtherATC