Provider Demographics
NPI:1487742417
Name:KINSEY, STACEY (PT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KINSEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 BIRCHWOOD CT
Mailing Address - Street 2:SUITE S
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2930
Mailing Address - Country:US
Mailing Address - Phone:515-471-9720
Mailing Address - Fax:515-471-9725
Practice Address - Street 1:2901 86TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4201
Practice Address - Country:US
Practice Address - Phone:515-276-3406
Practice Address - Fax:515-276-5141
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3667225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665430Medicaid
IA719260396Medicare PIN
IA0665430Medicaid
IAI19172Medicare PIN