Provider Demographics
NPI:1346306404
Name:STACEY-ROBAR, JUDITH E (ARNP)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:E
Last Name:STACEY-ROBAR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10041 SE 220TH ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-2509
Mailing Address - Country:US
Mailing Address - Phone:253-520-7086
Mailing Address - Fax:253-859-0043
Practice Address - Street 1:1851 CENTRAL PL S
Practice Address - Street 2:SUITE 123
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7514
Practice Address - Country:US
Practice Address - Phone:253-520-3060
Practice Address - Fax:253-859-0043
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006451363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9638511Medicaid
WA227130100000OtherPREMERA BLUE CROSS
WA8307-01OtherPACIFICARE BEHAVIORAL HEA
WA5240STOtherREGENCE BLUE SHIELD
WA0007266542OtherAETNA