Provider Demographics
NPI:1306121447
Name:TRIPP, STACY LYNN (PT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:TRIPP
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:GORSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:TERRA CEIA ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34250-0039
Mailing Address - Country:US
Mailing Address - Phone:941-758-2111
Mailing Address - Fax:941-758-2082
Practice Address - Street 1:4442 5TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1531
Practice Address - Country:US
Practice Address - Phone:941-758-2111
Practice Address - Fax:941-758-2082
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT24087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist