1497038731 NPI number — LEANDRA JONICOLE STEWART PHD

Table of content: LEANDRA JONICOLE STEWART PHD (NPI 1497038731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497038731 NPI number — LEANDRA JONICOLE STEWART PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEWART
Provider First Name:
LEANDRA
Provider Middle Name:
JONICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHIPLEY
Provider Other First Name:
LEANDRA
Provider Other Middle Name:
JONICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497038731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
126 SW 148TH ST
Provider Second Line Business Mailing Address:
STE C100-BOX #565
Provider Business Mailing Address City Name:
BURIEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98166-1984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-495-2888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10011 21ST AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98146-3704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-495-2888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY60649774 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)