Healthcare Provider Details

I. General information

NPI: 1861810624
Provider Name (Legal Business Name): STEPHANIE ROSE SRUR D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 12TH AVE NE
OLYMPIA WA
98506-5175
US

IV. Provider business mailing address

3539 SURREY DR NE
OLYMPIA WA
98506-3627
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-8470
  • Fax: 360-413-8490
Mailing address:
  • Phone: 360-907-5008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number60735930
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number94-08426
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: