1861546913 NPI number — MRS. STACEY ELIZABETH BEAUDOIN AUD

Table of content: MRS. STACEY ELIZABETH BEAUDOIN AUD (NPI 1861546913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861546913 NPI number — MRS. STACEY ELIZABETH BEAUDOIN AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAUDOIN
Provider First Name:
STACEY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STRUNKS
Provider Other First Name:
STACEY
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1861546913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1135 116TH AVE NE SUITE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-454-3938
Provider Business Mailing Address Fax Number:
425-454-2568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1135 116TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-454-3938
Provider Business Practice Location Address Fax Number:
425-454-2568
Provider Enumeration Date:
01/23/2007

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: 231H00000X , with the licence number:  LD00004422 , 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)

  • Identifier: 65043U . This is a "REGENCE BLUESHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8476038 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0218801 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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