Provider Demographics
NPI:1104092857
Name:BLUM, STEPHANIE RENEE (FNP)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:RENEE
Last Name:BLUM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8824 96TH ST NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-6303
Mailing Address - Country:US
Mailing Address - Phone:360-600-7269
Mailing Address - Fax:
Practice Address - Street 1:8824 96TH ST NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-6303
Practice Address - Country:US
Practice Address - Phone:360-600-7269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60071587363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8917373OtherMEDICARE PTAN
WA8507568OtherDSHS
WA8871633OtherMEDICARE
WA8871633OtherMEDICARE