MEDICARE: ALICIA STEPHENS ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1598412462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA STEPHENS ATC

Provider Business Mailing Address
First Line	:	851 SW MILLER RD
Second Line	:
City	:	PORT ORCHARD
State	:	WA
Zip	:	98367-9336
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13711 12ST ST
Second Line	:	BLDG 13815
City	:	JOINT BASE LEWIS MCCHORD
State	:	WA
Zip	:	98498
Country	:	US
Telephone Number	:	253-477-5558
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	11/03/2022

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