Basic Information
| Provider Information | |||||||||
| NPI: | 1669693222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENNIS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | KAYS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KAYS | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1100 NINTH AVE, DEPT OF PHYSICAL MEDICINE & REHAP(H4-PM | ||||||||
| Address2: | VIRGINIA MASON MEDICAL CENTER | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1100 NINTH AVE | ||||||||
| Address2: | VIRGINIA MASON MEDICAL CENTER | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063410461 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2540154 | WI | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | LL60032975 | WA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 8567869 | 05 | WA | MEDICAID |