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Individual

STACEY JO RUSSELL

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
PTA

Contact information

Practice address
4700 NW CLIFF VIEW DR, RIVERSIDE, MO 64150-1237
(816) 741-5105
Mailing address
4700 NW CLIFF VIEW DR, RIVERSIDE, MO 64150-1237

Taxonomy

Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
001388
IA
225200000X
Physical Therapy Assistant
Primary
2015030162
MO

Other

Enumeration date
10/26/2012
Last updated
05/25/2020
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