Healthcare Provider Details

I. General information

NPI: 1922502665
Provider Name (Legal Business Name): AUDRA STALLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4238
US

IV. Provider business mailing address

521 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4238
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-2938
  • Fax: 253-403-2968
Mailing address:
  • Phone: 253-403-2938
  • Fax: 253-403-2968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61102565
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: