Provider Demographics
NPI:1598951378
Name:SHIDEMANTLE, STACY R (LMT)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:R
Last Name:SHIDEMANTLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SUDDUTH CIR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5124
Mailing Address - Country:US
Mailing Address - Phone:850-543-4919
Mailing Address - Fax:
Practice Address - Street 1:301 SUDDUTH CIR NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5124
Practice Address - Country:US
Practice Address - Phone:850-543-4919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA49802225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist