Provider Demographics
NPI:1508304585
Name:STULL, BETHANY (LMP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:STULL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 SW 320TH ST APT 25
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-2260
Mailing Address - Country:US
Mailing Address - Phone:253-797-6336
Mailing Address - Fax:
Practice Address - Street 1:1310 S UNION AVE
Practice Address - Street 2:STE A-202
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1907
Practice Address - Country:US
Practice Address - Phone:253-507-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60622268174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA47-1101118OtherLMP