Provider Demographics
NPI:1043735889
Name:QUIMBY, STEPHANIE SUZAN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:SUZAN
Last Name:QUIMBY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7423 LUCINDA CT SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-9399
Mailing Address - Country:US
Mailing Address - Phone:360-888-5936
Mailing Address - Fax:
Practice Address - Street 1:1202 BLACK LAKE BLVD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502
Practice Address - Country:US
Practice Address - Phone:360-888-5936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-12
Last Update Date:2017-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60014330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist