Healthcare Provider Details

I. General information

NPI: 1952703258
Provider Name (Legal Business Name): STEPHANIE PEACE REZENDES PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 7TH AVE
SEATTLE WA
98104-1132
US

IV. Provider business mailing address

904 7TH AVE
SEATTLE WA
98104-1132
US

V. Phone/Fax

Practice location:
  • Phone: 206-860-2346
  • Fax: 206-860-4696
Mailing address:
  • Phone: 206-860-2346
  • Fax: 206-860-4696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number3902000X
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number3902000X
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60613322
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: