Provider Demographics
NPI:1205477361
Name:SANDERSON, STEPHANIE (NP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:SIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-397-4040
Mailing Address - Fax:
Practice Address - Street 1:2005 W MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-4311
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61006352363LC1500X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health