Healthcare Provider Details

I. General information

NPI: 1043768682
Provider Name (Legal Business Name): ANGELA ANN FASANELLA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 STATE AVE N # 200
KENT WA
98030-4543
US

IV. Provider business mailing address

PO BOX 5299 MS: 820-5-PCO
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 253-372-7849
  • Fax: 253-372-7844
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173959
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP.AP.61153619-NP
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: