Basic Information
Provider Information | |||||||||
NPI: | 1104878438 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STROM | ||||||||
FirstName: | MARJORIE | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | BOX 359797 | ||||||||
Address2: | 325 9TH AVE | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981042499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2067449600 | ||||||||
FaxNumber: | 2067449920 | ||||||||
Practice Location | |||||||||
Address1: | 325 9TH AVE | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981042499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2067443000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 06/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP30003735 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LP0808X | AP30003735 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 9627266 | 05 | WA |   | MEDICAID | 62208U | 01 | WA | REGENCE BLUE SHIELD PIN | OTHER | 0155130 | 01 | WA | L&I PIN | OTHER |