=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649081035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY LYNN QUEZADA DUBOIS NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2025
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12406 E DESMET AVE
-----------------------------------------------------
City | SPOKANE VALLEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99216-2996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-688-0147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24104 S HORSE HAVEN LN
-----------------------------------------------------
City | CHENEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99004-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-978-5329
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP61452970
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------