Provider Demographics
NPI:1295182574
Name:MACK HARMON, STEPHANIE A
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:MACK HARMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8980 161ST AVE NE STE 320
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-7554
Mailing Address - Country:US
Mailing Address - Phone:425-883-3333
Mailing Address - Fax:425-869-4854
Practice Address - Street 1:8980 161ST AVE NE STE 320
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-7554
Practice Address - Country:US
Practice Address - Phone:425-883-3333
Practice Address - Fax:425-869-4854
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAPA60795287363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program