Provider Demographics
NPI:1881208411
Name:STEWART, TAYLOR NICOLE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:STEWART
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 1:7638 SONGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98240-9310
Mailing Address - Country:US
Mailing Address - Phone:956-245-4206
Mailing Address - Fax:
Practice Address - Street 1:1610 GROVER ST STE B2
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1539
Practice Address - Country:US
Practice Address - Phone:360-354-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160999084225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant