=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609057397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY PENNY LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2007
-----------------------------------------------------
Last Update Date | 12/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5548 MYRTLE AVE STE 202
-----------------------------------------------------
City | FREELAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98249-8776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-914-2068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7019 HIGH MEADOW DR
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98236-8701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-914-2068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA00022531
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------