Healthcare Provider Details

I. General information

NPI: 1104198183
Provider Name (Legal Business Name): NANCY J STANCIK LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CROFT AVE
GOLD BAR WA
98251
US

IV. Provider business mailing address

PO BOX 175
GOLD BAR WA
98251
US

V. Phone/Fax

Practice location:
  • Phone: 360-793-0904
  • Fax: 360-799-0923
Mailing address:
  • Phone: 360-793-0904
  • Fax: 360-799-0923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00021300
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: