Provider Demographics
NPI:1821375155
Name:BROWN, STACIE R
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:R
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 SE WINDSOR CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5850
Mailing Address - Country:US
Mailing Address - Phone:360-633-6735
Mailing Address - Fax:
Practice Address - Street 1:2505 SE MILE HILL DR
Practice Address - Street 2:SUITE B-23
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3521
Practice Address - Country:US
Practice Address - Phone:360-633-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2012-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60255070172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist