Basic Information
| Provider Information | |||||||||
| NPI: | 1255842373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STITTLEBURG-DEVINE | ||||||||
| FirstName: | TARYN | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STITTLEBURG | ||||||||
| OtherFirstName: | TARYN | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4201 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525643888 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525643888 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2017 | ||||||||
| LastUpdateDate: | 10/16/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 6400 | MN | Y | Chiropractic Providers | Chiropractor |
No ID Information.