1588742704 NPI number — MS. STACEY LYN DURNBAUGH PALMER MPT

Table of content: MS. STACEY LYN DURNBAUGH PALMER MPT (NPI 1588742704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588742704 NPI number — MS. STACEY LYN DURNBAUGH PALMER MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALMER
Provider First Name:
STACEY
Provider Middle Name:
LYN DURNBAUGH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588742704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
513 N 64TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53213-4049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 HOLLISTER DR
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-5263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-918-7947
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  9724-024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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