Provider Demographics
NPI:1194841262
Name:AHERN, STEPHANIE (LMP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:AHERN
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 1:20504 123RD STREET CT E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-7448
Mailing Address - Country:US
Mailing Address - Phone:253-862-3186
Mailing Address - Fax:
Practice Address - Street 1:22015 STATE ROUTE 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-4241
Practice Address - Country:US
Practice Address - Phone:253-891-9109
Practice Address - Fax:253-826-0438
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016830225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0163130OtherW.C. & L&I NUMBER
WA0210469OtherW.C. & L&I NUMBER
WA8853343Medicare ID - Type UnspecifiedMEDICARE GRP. NUMBER