Provider Demographics
NPI:1508408303
Name:VANWAVEREN, STACEY S (LMT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:S
Last Name:VANWAVEREN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3729 SWAN CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-8578
Mailing Address - Country:US
Mailing Address - Phone:360-941-9545
Mailing Address - Fax:
Practice Address - Street 1:403 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3849
Practice Address - Country:US
Practice Address - Phone:360-941-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-13
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60973308225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist