Provider Demographics
NPI:1053694141
Name:CAPPON, STACEY T (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:T
Last Name:CAPPON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 WINDCREST DR
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1925
Mailing Address - Country:US
Mailing Address - Phone:315-487-3519
Mailing Address - Fax:
Practice Address - Street 1:201 WINDCREST DR
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1925
Practice Address - Country:US
Practice Address - Phone:315-487-3519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63005501174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist