Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 05005975A | IN |
Y | 2251X0800X | Physical Therapist - Orthopedic | 05005975A | IN |
NPI | 1053890681 |
---|---|
Provider Name | Sandra Jane Staley |
First Address | Carmel, IN 46032-8708 |
Second Address | Carmel, IN 46032 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2018 |
Last Update Date | 26/06/2019 |