Provider Demographics
NPI:1528261989
Name:KENNELLY, STACY ANN (MA PT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:MA PT
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:STANEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA PT
Mailing Address - Street 1:2877 NORTHERN DRIVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880
Mailing Address - Country:US
Mailing Address - Phone:715-392-4965
Mailing Address - Fax:
Practice Address - Street 1:1612 N 37TH STREET
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880
Practice Address - Country:US
Practice Address - Phone:715-392-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6496024225100000X
MN5371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40382400Medicaid