Provider Demographics
NPI:1376993576
Name:EDWARDS, STACIE LYNN
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:EDWARDS
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:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-0248
Mailing Address - Country:US
Mailing Address - Phone:360-791-6565
Mailing Address - Fax:
Practice Address - Street 1:4520 INTELCO LOOP SE
Practice Address - Street 2:STE 3A
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6008
Practice Address - Country:US
Practice Address - Phone:360-791-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist