Provider Demographics
NPI:1336174200
Name:NORDRUM, STACIE LYNNE (AUD)
Entity type:Individual
Prefix:DR
First Name:STACIE
Middle Name:LYNNE
Last Name:NORDRUM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1863
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250
Mailing Address - Country:US
Mailing Address - Phone:360-298-1369
Mailing Address - Fax:360-378-9556
Practice Address - Street 1:545 SPRING ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-8057
Practice Address - Country:US
Practice Address - Phone:360-378-2330
Practice Address - Fax:360-378-9556
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAI00004085231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8883249Medicare PIN