Provider Demographics
NPI:1144634601
Name:JOHN, STACEY (ATC, OTC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 NININGER RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55033-1086
Mailing Address - Country:US
Mailing Address - Phone:651-968-5413
Mailing Address - Fax:651-437-2988
Practice Address - Street 1:3580 ARCADE ST
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-7135
Practice Address - Country:US
Practice Address - Phone:651-968-5375
Practice Address - Fax:651-968-5907
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18-2775246ZC0007X
MN22802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant