Provider Demographics
NPI:1902912009
Name:WHITSON, STACI LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:LOUISE
Last Name:WHITSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:LOUISE
Other - Last Name:RUDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:12 RED MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52214-9537
Mailing Address - Country:US
Mailing Address - Phone:319-350-6990
Mailing Address - Fax:
Practice Address - Street 1:12 RED MAPLE CT
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:IA
Practice Address - Zip Code:52214-9537
Practice Address - Country:US
Practice Address - Phone:319-350-6990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02696225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
421494864OtherTRICARE
421494864OtherMIDLANDS CHOICE
421494864OtherACCOUNTABLE HEALTH PLAN
421494864OtherFIRST HEALTH MAIL HANDLER
42149864OtherPRIVATE HEALTH CARE SYSTE
7202080OtherAETNA
0100OtherJOHN DEERE
IA06745OtherWELLMARK BCBS
IA06745Medicare ID - Type Unspecified