Provider Demographics
NPI:1124666722
Name:LUCE, MISTY GAYLE (PTA)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:GAYLE
Last Name:LUCE
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 1:201 CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:KS
Mailing Address - Zip Code:67843
Mailing Address - Country:US
Mailing Address - Phone:620-227-2121
Mailing Address - Fax:
Practice Address - Street 1:714 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:KS
Practice Address - Zip Code:67843-9068
Practice Address - Country:US
Practice Address - Phone:620-227-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03536225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant