Provider Demographics
NPI:1528271533
Name:NYBORG, STEPHANIE RENEE (PTA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
Last Name:NYBORG
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 1:205 BENTON DR APT 7302
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-8589
Mailing Address - Country:US
Mailing Address - Phone:972-678-0280
Mailing Address - Fax:
Practice Address - Street 1:5515 GLEN LAKES DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4309
Practice Address - Country:US
Practice Address - Phone:214-361-8923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2058380225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant