Provider Demographics
NPI:1215125513
Name:MEARDON, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MEARDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:BURKHARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1454 30TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1305
Mailing Address - Country:US
Mailing Address - Phone:515-223-6620
Mailing Address - Fax:515-223-9625
Practice Address - Street 1:1454 30TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1305
Practice Address - Country:US
Practice Address - Phone:515-223-6620
Practice Address - Fax:515-223-9625
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02969225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665190Medicaid
IA0665190Medicaid