Basic Information
| Provider Information | |||||||||
| NPI: | 1912225160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 SOUTHPOINT LN | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253720 | ||||||||
| FaxNumber: | 5095254691 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 SOUTHPOINT LN | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253720 | ||||||||
| FaxNumber: | 5095254691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD61083925 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 131351 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.