Provider Demographics
NPI:1053749762
Name:DIBBLE, STACY LYNN
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:DIBBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 GABBEY RD
Mailing Address - Street 2:
Mailing Address - City:CORFU
Mailing Address - State:NY
Mailing Address - Zip Code:14036-9788
Mailing Address - Country:US
Mailing Address - Phone:585-356-4494
Mailing Address - Fax:
Practice Address - Street 1:1051 GABBEY RD
Practice Address - Street 2:
Practice Address - City:CORFU
Practice Address - State:NY
Practice Address - Zip Code:14036-9788
Practice Address - Country:US
Practice Address - Phone:585-356-4494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007041-1225200000X
NY016327-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist