Provider Demographics
NPI:1871110882
Name:HERONEMA, STACEY KRISTINE (DPT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:KRISTINE
Last Name:HERONEMA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3776 PALISADE DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3705
Mailing Address - Country:US
Mailing Address - Phone:303-548-7151
Mailing Address - Fax:
Practice Address - Street 1:718 N MAIN ST UNIT 18
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2412
Practice Address - Country:US
Practice Address - Phone:970-641-7389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0017056225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist