Healthcare Provider Details

I. General information

NPI: 1780503805
Provider Name (Legal Business Name): STEPHANIE SHIELDS CPE, CLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N TOWER AVE
CENTRALIA WA
98531-4219
US

IV. Provider business mailing address

103 N TOWER AVE
CENTRALIA WA
98531-4219
US

V. Phone/Fax

Practice location:
  • Phone: 360-489-6952
  • Fax:
Mailing address:
  • Phone: 360-489-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberBAP-E-10250463
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: