Provider Demographics
NPI:1669571394
Name:STAVISH, BRENDA LEE ANITA MARIE (BSN MSN ARNP)
Entity type:Individual
Prefix:
First Name:BRENDA LEE
Middle Name:ANITA MARIE
Last Name:STAVISH
Suffix:
Gender:F
Credentials:BSN MSN ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2916 N 32ND ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-6436
Mailing Address - Country:US
Mailing Address - Phone:206-890-8074
Mailing Address - Fax:206-244-6726
Practice Address - Street 1:16233 SYLVESTER RD SW
Practice Address - Street 2:SUITE G40
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3045
Practice Address - Country:US
Practice Address - Phone:206-244-6625
Practice Address - Fax:206-244-6726
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAP30007442363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0219212OtherL&I
WA1669571394Medicaid
WA8881278Medicare PIN