Provider Demographics
NPI:1932794310
Name:NIELSEN, STACEA
Entity Type:Individual
Prefix:
First Name:STACEA
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CAMANCHE
Mailing Address - State:IA
Mailing Address - Zip Code:52730-2119
Mailing Address - Country:US
Mailing Address - Phone:563-249-3217
Mailing Address - Fax:
Practice Address - Street 1:849 13TH AVE N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-5168
Practice Address - Country:US
Practice Address - Phone:563-242-1521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-07
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA106352225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist