Provider Demographics
NPI:1164218764
Name:STEFANOVA, IRINA (MA61677022)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:STEFANOVA
Suffix:
Gender:F
Credentials:MA61677022
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 S 52ND ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-1436
Mailing Address - Country:US
Mailing Address - Phone:253-290-6030
Mailing Address - Fax:
Practice Address - Street 1:1700 S 305TH PL STE A
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4804
Practice Address - Country:US
Practice Address - Phone:253-941-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61677022225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist