Provider Demographics
NPI:1215561956
Name:LOVELAND, STEPHANIE NICOLE (ATC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:LOVELAND
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICOLE
Other - Last Name:LYDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:6836 N SMITH ST APT A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-2579
Mailing Address - Country:US
Mailing Address - Phone:503-752-0730
Mailing Address - Fax:
Practice Address - Street 1:5405 SE WOODWARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2168
Practice Address - Country:US
Practice Address - Phone:503-916-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-101696872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer