Basic Information
| Provider Information | |||||||||
| NPI: | 1669571394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAVISH | ||||||||
| FirstName: | BRENDA LEE | ||||||||
| MiddleName: | ANITA MARIE | ||||||||
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| Credential: | BSN MSN ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2916 N 32ND ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984076436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068908074 | ||||||||
| FaxNumber: | 2062446726 | ||||||||
| Practice Location | |||||||||
| Address1: | 16233 SYLVESTER RD SW | ||||||||
| Address2: | SUITE G40 | ||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062446625 | ||||||||
| FaxNumber: | 2062446726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | AP30007442 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 0219212 | 01 | WA | L&I | OTHER | 1669571394 | 05 | WA | MEDICAID |