Provider Demographics
NPI:1316205511
Name:EASTIN, STEPHANIE (LAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:EASTIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 SE PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-7825
Mailing Address - Country:US
Mailing Address - Phone:608-769-5135
Mailing Address - Fax:503-893-3045
Practice Address - Street 1:223 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7605
Practice Address - Country:US
Practice Address - Phone:503-667-1500
Practice Address - Fax:503-893-3045
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR156812171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR156812OtherACUPUNCTURE LICENSE