Provider Demographics
NPI:1952428799
Name:FULL, STEPHANIE JANE (PTA)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:JANE
Last Name:FULL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ELIZABETH ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-2185
Mailing Address - Country:US
Mailing Address - Phone:304-984-0046
Mailing Address - Fax:304-984-3875
Practice Address - Street 1:302 CEDAR RIDGE RD
Practice Address - Street 2:
Practice Address - City:SISSONVILLE
Practice Address - State:WV
Practice Address - Zip Code:25320-9502
Practice Address - Country:US
Practice Address - Phone:304-984-0046
Practice Address - Fax:304-984-0356
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1104225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant