Provider Demographics
NPI:1740225077
Name:SIPE, STEPHANIE R (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:R
Last Name:SIPE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24312 NE 142ND AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-9412
Mailing Address - Country:US
Mailing Address - Phone:503-504-2182
Mailing Address - Fax:
Practice Address - Street 1:4503 OCEAN BEACH HWY STE 103
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-5055
Practice Address - Country:US
Practice Address - Phone:360-636-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00004012152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031748Medicaid
WA1073SIOtherNORTHWEST BENEFIT NETWORK