Provider Demographics
NPI:1790138469
Name:STEVENSON, ANGELA LYNN (LMT #15856)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LYNN
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LMT #15856
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 NW TEAK AVE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1234
Mailing Address - Country:US
Mailing Address - Phone:541-948-7090
Mailing Address - Fax:
Practice Address - Street 1:716 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2648
Practice Address - Country:US
Practice Address - Phone:541-948-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT #15856172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker