Provider Demographics
NPI:1912234659
Name:STEVENSON, FAIRUZA MAGSUM (NP STUDENT)
Entity Type:Individual
Prefix:
First Name:FAIRUZA
Middle Name:MAGSUM
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:NP STUDENT
Other - Prefix:
Other - First Name:FAIA
Other - Middle Name:MAGSUM
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14204 NE SALMON CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-9600
Mailing Address - Country:US
Mailing Address - Phone:360-882-7008
Mailing Address - Fax:
Practice Address - Street 1:700 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663
Practice Address - Country:US
Practice Address - Phone:360-254-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00139022390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program