Provider Demographics
NPI:1124214267
Name:VAN TASSEL, STACEY JONELLE (LMP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JONELLE
Last Name:VAN TASSEL
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 1:26615 199TH PL SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-5087
Mailing Address - Country:US
Mailing Address - Phone:253-670-5910
Mailing Address - Fax:
Practice Address - Street 1:29034 216TH AVE SE
Practice Address - Street 2:
Practice Address - City:BLACK DIAMOND
Practice Address - State:WA
Practice Address - Zip Code:98010-1297
Practice Address - Country:US
Practice Address - Phone:360-886-2649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020492174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist