Healthcare Provider Details

I. General information

NPI: 1831357185
Provider Name (Legal Business Name): STACEY MARIE SMITH LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 N 155TH ST
SHORELINE WA
98133-6014
US

IV. Provider business mailing address

1816 N 155TH ST
SHORELINE WA
98133-6014
US

V. Phone/Fax

Practice location:
  • Phone: 206-356-8473
  • Fax:
Mailing address:
  • Phone: 206-356-8473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberMA00015667
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: