Provider Demographics
NPI:1184871725
Name:COULARDOT, STACEY LYNN
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYNN
Last Name:COULARDOT
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2380 N 300 W
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-9734
Mailing Address - Country:US
Mailing Address - Phone:260-694-6318
Mailing Address - Fax:
Practice Address - Street 1:2380 N 300 W
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-9734
Practice Address - Country:US
Practice Address - Phone:260-694-6318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001396A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant