Healthcare Provider Details

I. General information

NPI: 1396562021
Provider Name (Legal Business Name): LORRAINE RAYANN BARNETTE SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORRAINE RAYANN STONER

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 HOWANUT RD
OAKVILLE WA
98568-9659
US

IV. Provider business mailing address

420 HOWANUT RD
OAKVILLE WA
98568-9659
US

V. Phone/Fax

Practice location:
  • Phone: 360-709-1682
  • Fax:
Mailing address:
  • Phone: 360-709-1682
  • Fax: 707-274-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61446517
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: