Basic Information
| Provider Information | |||||||||
| NPI: | 1770124513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDT | ||||||||
| FirstName: | STEFANIE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORGAN | ||||||||
| OtherFirstName: | STEFANIE | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4332 189TH PL NE | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982234243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252441128 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1570 WILMINGTON DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | DUPONT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983278773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064534882 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.