Provider Demographics
NPI:1629312681
Name:STEPHENS, ERICA N (LMP)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:N
Last Name:STEPHENS
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:PO BOX 15231
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-0231
Mailing Address - Country:US
Mailing Address - Phone:425-443-9624
Mailing Address - Fax:
Practice Address - Street 1:875 140TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005
Practice Address - Country:US
Practice Address - Phone:425-462-6604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60229226174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 60229226OtherLMP