Provider Demographics
NPI:1306154190
Name:STUCKEY, BREANNE ALANNA (DPT)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:ALANNA
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:ALANNA
Other - Last Name:STAPLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:450 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-3045
Mailing Address - Country:US
Mailing Address - Phone:515-323-6485
Mailing Address - Fax:515-323-6486
Practice Address - Street 1:450 LAUREL ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3045
Practice Address - Country:US
Practice Address - Phone:515-323-6485
Practice Address - Fax:515-323-6486
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAPT04587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI19172036Medicare PIN
IAI19172Medicare PIN