Basic Information
Provider Information | |||||||||
NPI: | 1740753748 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUZMAN-FIX | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2020 LAKE HEIGHTS DR APT D104 | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982086060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4257369530 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4308 76TH ST NE | ||||||||
Address2: |   | ||||||||
City: | MARYSVILLE | ||||||||
State: | WA | ||||||||
PostalCode: | 982703720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253497352 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2019 | ||||||||
LastUpdateDate: | 01/02/2019 | ||||||||
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 | 246Z00000X | CM60379774 | WA | N |   | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |   | 246ZX2200X | CM60379774 | WA | Y |   |   |   |   |
No ID Information.