Provider Demographics
NPI:1053542746
Name:MITCHELL, STACIA ANN (PTA)
Entity type:Individual
Prefix:MS
First Name:STACIA
Middle Name:ANN
Last Name:MITCHELL
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 1:301 PANORAMA BLVD APT 705
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-7277
Mailing Address - Country:US
Mailing Address - Phone:620-617-4914
Mailing Address - Fax:
Practice Address - Street 1:3101 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-9713
Practice Address - Country:US
Practice Address - Phone:575-434-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0668225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant