Provider Demographics
NPI:1871118018
Name:MACA, STEPHANNIE JO (ATC)
Entity type:Individual
Prefix:
First Name:STEPHANNIE
Middle Name:JO
Last Name:MACA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:STEPHANNIE
Other - Middle Name:JO
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:7526 N 279TH ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:NE
Mailing Address - Zip Code:68064-8046
Mailing Address - Country:US
Mailing Address - Phone:402-366-2561
Mailing Address - Fax:
Practice Address - Street 1:5120 MAPLE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-3555
Practice Address - Country:US
Practice Address - Phone:402-366-2561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer