Healthcare Provider Details

I. General information

NPI: 1407789001
Provider Name (Legal Business Name): IDALIS AMADALEY LICEA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 CHARDONNAY AVE
PROSSER WA
99350-9515
US

IV. Provider business mailing address

1611 DIAMOND AVE
GRANDVIEW WA
98930-6118
US

V. Phone/Fax

Practice location:
  • Phone: 509-786-1576
  • Fax:
Mailing address:
  • Phone: 509-786-1576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number61382393
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: