Provider Demographics
NPI:1861907719
Name:NICKELS, STEFANIE (HIS)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:NICKELS
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 NW BUCKLIN HILL RD STE 103
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8359
Mailing Address - Country:US
Mailing Address - Phone:360-692-6650
Mailing Address - Fax:
Practice Address - Street 1:3100 NW BUCKLIN HILL RD STE 103
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8359
Practice Address - Country:US
Practice Address - Phone:360-692-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA60742985237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty